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OBJECTIVE: To explore the Canadian first-trimester medication abortion (MA) workforce and their clinical care following the introduction of mifepristone in 2017, updated national clinical practice guidelines and government approval of nurse practitioners (NPs) as first-trimester MA providers. STUDY DESIGN: We conducted a national, self-administered, cross-sectional survey of abortion providers in 2019. Our bilingual (French/English) survey collected information on demographics, abortion number, and clinical care characteristics. The true number of abortion providers is unknown thus we cannot calculate a survey response rate. To maximize identification of possibly eligible respondents, we widely distributed the survey between July and December 2020 through health professional organizations, using a modified Dillman technique. We used descriptive statistics to characterize the workforce and clinical practices. RESULTS: Four-hundred-sixty-five clinicians responded, of whom 388 provided first-trimester MA. Physicians (n = 358) and NPs (n = 30) reported providing 13,429 first-trimester MAs in 2019 which represented 27.7% of all reported abortions in the survey. The majority of first-trimester MA respondents were primary care physicians (n = 245, 63.1%), had less than five years' experience (n = 223, 61.3%) and practiced outside of hospitals (n = 228, 66.5%). Forty-three percent (n = 165) practiced rurally, and 44.0% (n = 136) used telemedicine for some abortion care. Ninety-nine percent (n = 350) used a guideline-recommended mifepristone/misoprostol regimen while 14.5% (n = 51) sometimes used methotrexate. Patients most commonly received mifepristone/misoprostol at community pharmacies (median 100.0%; interquartile range 50.0%-100.0%). CONCLUSION: Our results suggest that there are many new first-trimester MA providers, an increase in the proportion of MAs since 2012 and a shift to primary care settings. Respondents widely adopted mifepristone. IMPLICATIONS STATEMENT: Our results highlight that, following mifepristone introduction, many new primary care practitioners started providing first-trimester medication abortion throughout Canada, including the first non-physicians. This increased access to abortion particularly in rural and underserved communities. These results could inform future directions in policy, guidelines, and abortion access initiatives.

Manual uterine aspiration (MUA) is a currently underused management option for early pregnancy loss (EPL) in the emergency department (ED). This study addresses the safety and efficiency of MUA in the ED.We performed a single-site retrospective observational chart review of pregnant women presenting to the ED with vaginal bleeding and ED pathology submissions for products of conception (POC) between 2012 and 2016. Patients were excluded for gestational age14 weeks, no evidence of pregnancy loss, uterine cavity anomaly, hemodynamic instability, or hemoglobin80 g/L. We compared the frequencies of complications (need for blood transfusion, repeat ED visit, failed initial management, admission to hospital) and ED utilization time between 4 management options: expectant, misoprostol, MUA, and electric vacuum aspiration (EVA) outside the ED, as well as time to procedure between MUA and EVA.A total of 162 patients were included with 123 (76%) having a pathology report positive for POC. The mean patient and gestational ages were 30 ± 7 years and 66 ± 17 days, respectively. One hundred nine patients were managed expectantly, 9 were given misoprostol, 23 underwent MUA, and 21 underwent EVA. Composite complication rates were 40%, 33%, 9%, and 10% (P = 0.001), and mean ED times were 5.4, 4.9, 7.3, and 6.0 hours (P = 0.01), for expectant, misoprostol, MUA, and EVA, respectively. The mean time to procedure was 5.1 hours for MUA and 23.1 hours for EVA (p=0.002).Integrating MUA in the ED has the potential to reduce health care resource utilization while improving patient care.

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.

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Chapter 8: Progestin-Only Contraception Summary Statements 15.Progestin implants have failure rates as low as permanent contraception. (II-2) 16.The use of a progestin implant immediately postpartum and post-abortion is an effective way of decreasing repeat pregnancy in adolescents and repeat abortions. (II-2) 17.The most common side effect of progestin-only contraceptive methods is menstrual cycle disturbances. (II-2) Amenorrhea is very common with depot medroxyprogesterone acetate and progestin implant use. (II-2) 18.The use of progestins given at contraceptive doses does not appear to increase the risk of venous thromboembolism, myocardial infarction, or stroke. (II-2) 19.The efficacy of progestin implants or depot medroxyprogesterone acetate is not decreased in overweight and obese women. (II-2) 20.Early weight gain with depot medroxyprogesterone acetate use is predictive of continued weight gain. (II-2) 21.Depot medroxyprogesterone acetate use is associated with a delay in resumption of ovulation. (II-2) 22.The use of depot medroxyprogesterone acetate (DMPA) is associated with a decrease in bone mineral density. This decrease is most rapid in the first 2 years of use and appears to be largely reversible once DMPA is discontinued. (I) There is no strong evidence that the use of DMPA causes osteoporosis (II-2) or increases the risk of fracture. (II-2) 23.The use of progestin-only preparations has not been shown to decrease breast milk production. (I) The small amounts of steroid hormones secreted in breast milk do not have an adverse effect on infant growth and development. (II-2) 24.Depot medroxyprogesterone acetate use is associated with a decreased risk of endometrial and ovarian cancer. (II-2) Recommendations 12.Progestin-only methods of contraception should be considered in women with medical conditions where estrogen is contraindicated or less appropriate, such as women who are recently postpartum, breastfeeding, or in smokers over age 35. (III-A) 13.There should be no restriction on the use of depot medroxy-progesterone acetate (DMPA), including duration of use, among women of reproductive age who are otherwise eligible to use the method. The overall risks and benefits of continuing DMPA use should be discussed with DMPA users at regular intervals throughout the course of treatment. (III-A) 14.Counselling regarding menstrual cycle disturbances should be done prior to initiating a progestin-only method of contraception. (I-A) 15.Health care providers should inform patients of the potential effects of depot medroxyprogesterone acetate on bone mineral density and counsel them on "bone health," including calcium and vitamin D supplementation, smoking cessation, weight-bearing exercise, and decreased alcohol and caffeine consumption. (III-A) 16.If prolonged and/or frequent bleeding occurs in users of progestin-only contraceptives, pregnancy, sexually transmitted infection, and genital pathology should be ruled out. (III-B) 17.Ectopic pregnancy should be ruled out if a pregnancy occurs in a woman using a progestin-only method of contraception. (III-A)

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception , sexuality , sexual health ) et de mots cles (p. ex. contraception , family planning , hormonal contraception , emergency contraception ) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Chapitre 8 : Contraception a progestatif seul Declarations sommaires 15.Les implants de progestatif comptent des taux d'echec aussi faibles que ceux de la contraception permanente. (II-2) 16.L'insertion d'un implant immediatement a la suite d'un accouchement ou d'un avortement constitue une facon efficace d'abaisser les taux de nouvelle grossesse chez les adolescentes et de nouvel avortement. (II-2) 17.Les perturbations du cycle menstruel constituent l'effet indesirable le plus courant des modes de contraception a progestatif seul. (II-2) L'amenorrhee est tres courante dans le cadre de l'utilisation d'acetate de medroxyprogesterone-retard et d'implants de progestatif. (II-2) 18.L'utilisation de progestatifs administres selon des doses contraceptives ne semble pas accroitre le risque de thromboembolie veineuse, d'infarctus du myocarde ou d'accident vasculaire cerebral. (II-2) 19.L'efficacite des implants de progestatif (ou de l'acetate de medroxyprogesterone) n'est pas amoindrie chez les femmes obeses ou presentant une surcharge ponderale. (II-2) 20.La constatation d'un gain ponderal precoce dans le cadre de l'utilisation d'acetate de medroxyprogesterone-retard permet de predire la poursuite du gain ponderal. (II-2) 21.L'utilisation d'acetate de medroxyprogesterone-retard est associee a un delai quant a la reprise de l'ovulation. (II-2) 22.L'utilisation d'acetate de medroxyprogesterone-retard est associee a une baisse de la densite minerale osseuse. Cette baisse atteint sa rapidite maximale au cours des deux premieres annees d'utilisation et semble etre largement reversible a la suite de l'abandon du traitement a l'acetate de medroxyprogesterone-retard. (I) Nous ne disposons pas de donnees probantes solides indiquant que l'utilisation d'acetate de medroxyprogesterone-retard cause l'osteoporose (II-2) ou qu'elle entraine une hausse du risque de fracture. (II-2) 23.Il n'a pas ete demontre que l'utilisation de preparations a progestatif seul entraine une baisse de la production de lait maternel. (I) Les petites quantites d'hormones steroidiennes secretees dans le lait maternel n'exercent pas un effet indesirable sur la croissance et le developpement du nouveau-ne. (II-2) 24.L'utilisation d'acetate de medroxyprogesterone-retard est associee a une baisse des risques de cancer de l'endometre et de cancer de l'ovaire. (II-2) Recommandations 12.Le recours a des modes de contraception a progestatif seul devrait etre envisage chez les femmes qui presentent des troubles medicaux dans le cadre desquels la prise d'œstrogenes est contre-indiquee ou moins souhaitable, comme dans le cas des femmes qui ont recemment connu un accouchement, qui allaitent ou qui fument et qui sont âgees de plus de 35 ans. (III-A) 13.Aucune restriction ne devrait etre imposee quant a l'utilisation d'acetate de medroxyprogesterone-retard (y compris en ce qui a trait a la duree d'utilisation) chez les femmes en âge de procreer qui sont autrement admissibles a l'utilisation de ce mode de contraception. Les risques et les avantages globaux de la poursuite de l'utilisation d'acetate de medroxyprogesterone-retard devraient faire l'objet de discussions avec les utilisatrices a intervalles reguliers tout au long du traitement. (III-A) 14.Des services de counseling traitant des perturbations du cycle menstruel devraient etre offerts avant la mise en œuvre d'un mode de contraception a progestatif seul. (I-A) 15.Les fournisseurs de soins devraient aviser leurs patientes des effets potentiels de l'acetate de medroxyprogesterone-retard sur la densite minerale osseuse et leur offrir des conseils en matiere de « sante osseuse » (y compris en ce qui concerne la supplementation en calcium et en vitamine D, l'abandon du tabagisme, la pratique d'exercices de port de poids et l'attenuation de la consommation d'alcool et de cafeine). (III-A) 16.En presence de saignements prolonges et/ou frequents chez des utilisatrices de contraceptifs a progestatif seul, la presence d'une grossesse, d'une infection transmissible sexuellement ou d'une pathologie genitale devrait etre ecartee. (III-B) 17.La possibilite d'une grossesse ectopique doit etre ecartee lorsqu'une grossesse en vient a se manifester chez une femme qui utilise un mode de contraception a progestatif seul. (III-A)

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Chapter 7: Intrauterine Contraception Summary Statements 1.Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2.The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3.Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4.The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5.The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6.Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7.Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8.In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9.Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10.Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11.Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12.Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13.Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14.Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) Recommendations 1.Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2.In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3.Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4.Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5.A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6.Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7.In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8.In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9.Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10.Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Introduction Bacterial vaginosis (BV), characterized by Lactobacillus depletion and replacement by facultative or anaerobic bacteria, impacts up to 30% of women and associates with negative reproductive health outcomes. We used a systems immunology approach to investigate cellular and molecular inflammation associated with BV. Methods Matched cervical cytobrush and cervicovaginal lavage were collected from BV− (n=16) and BV+ (n=11) women. Cytobrushes were immunophenotyped by flow cytometry and lavages were analyzed by tandem mass spectrometry. Differences in immune cell levels were evaluated with Mann-Whitney U tests, and assessed against host and bacterial proteins using Spearman’s Rank correlations. Results There were no clinical or demographic differences between BV+ and BV− women, including age (range 22–49), birth control use and STI history. Proteomic analysis identified 1085 human proteins and 516 bacterial proteins from 14 genera, including Lactobacillus, Gardnerella, and Mobiluncus. Long living neutrophils (CD49d+) were significantly increased in BV+ women (p=0.0005), and associated with cell adhesion (p=4.04E-5), T cell mediated immunity (p=0.004), and regulation of myeloid differentiation (p=8.63E-16) pathways. CD49+ neutrophils correlated positively with Mobiluncus (p=0.040, R2=0.49) and negatively with Lactobacillus (p=0.035, R2=−0.498). Discussion This data indicates that cervical neutrophil survival is increased in women with BV. These cells associated with anaerobic bacteria and molecular pathways of immune activation. Studies are ongoing to delineate the relationship between BV-associated bacteria and neutrophil functionality, which may have implications for BV treatment.

Resume Objectif Fournir des lignes directrices aux fournisseurs de soins quant a l'utilisation de modes de contraception pour la prevention de la grossesse et quant a la promotion d'une sexualite saine. Issues Orientation des praticiens canadiens en ce qui concerne l'efficacite globale, le mecanisme d'action, les indications, les contre-indications, les avantages n'etant pas lies a la contraception, les effets indesirables, les risques et le protocole de mise en œuvre des modes de contraception abordes; planification familiale dans le contexte de la sante sexuelle et du bien-etre general; methodes de counseling en matiere de contraception; et accessibilite et disponibilite des modes de contraception abordes au Canada. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans MEDLINE et The Cochrane Library entre janvier 1994 et janvier 2015 au moyen d'un vocabulaire controle (p. ex. contraception , sexuality , sexual health ) et de mots cles (p. ex. contraception , family planning , hormonal contraception , emergency contraception ) appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1994 et janvier 2015. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en juin 2015. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general wellbeing; contraceptive counselling methods; and access to and availability of cited contraceptive methods in Canada. Evidence Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.Guidance for Canadian practitioners on overall effectiveness, mechanism of action, indications, contraindications, non-contraceptive benefits, side effects and risks, and initiation of cited contraceptive methods; family planning in the context of sexual health and general well-being; contraceptive counselling methods; and access to, and availability of, cited contraceptive methods in Canada.Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis and incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Chapter 1: Contraception in Canada Summary Statements 1. Canadian women spend a significant portion of their lives at risk of an unintended pregnancy. (II-2) 2. Effective contraceptive methods are underutilized in Canada, particularly among vulnerable populations. (II-2) 3. Long-acting reversible contraceptive methods, including contraceptive implants and intrauterine contraception (copper-releasing and levonorgestrel-releasing devices/systems), are the most effective reversible contraceptive methods and have the highest continuation rates. (II-1) 4. Canada currently does not collect reliable data to determine the use of contraceptive methods, abortion rates, and the prevalence of unintended pregnancy among reproductive-age women. (II-2) 5. A universal subsidy for contraceptive methods as provided by many of Canada's peer nations and a few Canadian provinces may produce health system cost-savings. (II-2) 6. Health Canada approval processes for contraceptives have been less efficient than those of other drug approval agencies and Health Canada processes for other classes of pharmaceuticals. (II-2) 7. It is feasible and safe for contraceptives and family planning services to be provided by appropriately trained allied health professionals such as midwives, registered nurses, nurse practitioners, and pharmacists. (II-2) Recommendations 1. Contraceptive counselling should include a discussion of typical use failure rates and the importance of using the contraceptive method consistently and correctly in order to avoid pregnancy. (II-2A) 2. Women seeking contraception should be counselled on the wide range of effective methods of contraception available, including long-acting reversible contraceptive methods (LARCs). LARCs are the most effective methods of reversible contraception, have high continuation rates, and should be considered when presenting contraceptive options to any woman of reproductive age. (II-2A) 3. Family planning counselling should include counselling on the decline of fertility associated with increasing female age. (III-A) 4. Health policy supporting a universal contraception subsidy and strategies to promote the uptake of highly effective methods as cost-saving measures that improve health and health equity should be considered by Canadian health decision makers. (III-B) 5. Canadian health jurisdictions should consider expanding the scope of practice of other trained professionals such as nurses, nurse practitioners, midwives, and pharmacists and promoting task-sharing in family planning. (II-2B) 6. The Canadian Community Health Survey should include adequate reproductive health indicators in order for health care providers and policy makers to make appropriate decisions regarding reproductive health policies and services in Canada. (III-B) 7. Health Canada processes and policies should be reviewed to ensure a wide range of modern contraceptive methods are available to Canadian women. (III-B) Chapter 2: Contraceptive Care and Access Summary Statements 8. Although there are many contraceptive options in Canada, only a narrow range of contraceptive methods are commonly used by those of reproductive age. (II-3) 9. Condom use decreases with longer relationship tenure and when the sexual partner is considered to be the main partner, likely due to a lower perceived risk of sexually transmitted infection in that relationship. Condom use may also decrease markedly as an unintended consequence when an effective non-barrier method, such as hormonal contraception or intrauterine contraception, is initiated. (II-3) 10. Family planning counselling provides a natural segue into screening for concerns about sexual function or intimate partner violence. (III) 11. Well-informed and well-motivated individuals who have developed skills to practise safer sex behaviours are more likely to use contraceptive and safer sex methods effectively and consistently. (II-2) Recommendations 8. Comprehensive family planning services, including abortion services, should be accessible to all Canadians regardless of geographic location. These services should be confidential, non-judgemental, and respectful of individuals' privacy and cultural contexts. (III-A) 9. A contraceptive visit should include history taking, screening for contraindications, dispensing or prescribing a method of contraception, and exploring contraceptive choice and adherence in the broader context of the individual's sexual behaviour, reproductive health risk, social circumstances, and relevant belief systems. (III-B) 10. Health care providers should provide practical information on the wide range of contraceptive options and their potential non-contraceptive benefits and assist women and their partners in determining the best user-method fit. (III-B) 11. Health care providers should assist women and men in developing the skills necessary to negotiate the use of contraception and the correct and consistent use of a chosen method. (III-B) 12. Contraceptive care should include discussion and management of the risk of sexually transmitted infection, including appropriate recommendations for condom use and dual protection, STI screening, post-exposure prophylaxis, and Hepatitis B and human papillomavirus vaccination. (III-B) 13. Health care providers should emphasize the use of condoms not only for protection against sexually transmitted infection, but also as a back-up method when adherence to a hormonal contraceptive may be suboptimal. (I-A) 14. Health care providers should be aware of current media controversies in reproductive health and acquire relevant evidence-based information that can be briefly and directly communicated to their patients. (III-B) 15. Referral resources for intimate partner violence, sexually transmitted infections, sexual dysfunction, induced abortion services, and child protection services should be available to help clinicians provide contraceptive care in the broader context of women's health. (III-B) Chapter 3: Emergency Contraception Summary Statements 12. The copper intrauterine device is the most effective method of emergency contraception. (II-2) 13. A copper intrauterine device can be used for emergency contraception up to 7 days after unprotected intercourse provided that pregnancy has been ruled out and there are no other contraindications to its insertion. (II-2) 14. Levonorgestrel emergency contraception is effective up to 5 days (120 hours) after intercourse; its effectiveness decreases as the time between unprotected intercourse and ingestion increases. (II-2) 15. Ulipristal acetate for emergency contraception is more effective than levonorgestrel emergency contraception up to 5 days after unprotected intercourse. This difference in effectiveness is more pronounced as the time from unprotected intercourse increases, especially after 72 hours. (I) 16. Hormonal emergency contraception (levonorgestrel emergency contraception and ulipristal acetate for emergency contraception) is not effective if taken on the day of ovulation or after ovulation. (II-2) 17. Levonorgestrel emergency contraception may be less effective in women with a body mass index25 kg/m2 and ulipristal acetate for emergency contraception may be less effective in women with a body mass index35 kg/m2. However, hormonal emergency contraception may still retain some effectiveness regardless of a woman's body weight or body mass index. (II-2) 18. Hormonal emergency contraception is associated with higher failure rates when women continue to have subsequent unprotected intercourse. (II-2) 19. Hormonal contraception can be initiated the day of or the day following the use of levonorgestrel emergency contraception, with back-up contraception used for the first 7 days. (III) 20. Hormonal contraception can be initiated 5 days following the use of ulipristal acetate for emergency contraception, with back-up contraception used for the first 14 days. (III) Recommendations 16. All emergency contraception should be initiated as soon as possible after unprotected intercourse. (II-2A) 17. Women should be informed that the copper intrauterine device (IUD) is the most effective method of emergency contraception and can be used by any woman with no contraindications to IUD use. (II-3A) 18.

Objective To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality. Outcomes Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the availability of cited contraceptive methods in Canada. Evidence Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1994 to December 2015 in order to update the Canadian Contraception Consensus published February-April 2004. Relevant Canadian government publications and position papers from appropriate health and family planning organizations were also reviewed. Values The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice are ranked according to the method described in this report. Summary Statements 1.Although highly effective with perfect use, typical use failure rates for combined hormonal contraceptives, including the combined oral contraceptive pill, are as high as 9% (II-2). 2.The majority of qualified studies do not indicate decreased combined oral contraceptive pill efficacy in obese women; however, a small increase in contraceptive failure in women with a body mass index greater than 30 cannot be excluded (II-2). 3.Combined oral contraceptive pills are associated with a number of non-contraceptive benefits, including but not limited to decreased menstrual bleeding, decreased acne, fewer endometriosis-related symptoms, and a decreased risk of ovarian and endometrial cancers (II-2). 4.Combined oral contraceptive pills (COCs) are associated with an increased risk of venous thromboembolism (II-2). Potential differences in the risk of venous thromboembolism attributable to different progestin types and estrogen dosing in low-dose COCs do not currently justify preferential prescribing (III). 5.Low-dose combined oral contraceptive pills (containing less than 50 μg of ethinyl estradiol) are not associated with an increased risk of myocardial infarction or cerebrovascular accident in women with no additional risk factors (II-2). 6.Current epidemiological studies suggest that there is no increase in the risk of breast cancer or breast cancer mortality in women who have used combined oral contraceptive pills (COCs) compared with non-users (II-2). There may be a slight increase in breast cancer in current and/or recent COC users (II-2). The use of COCs in BRCA1/2 carriers is controversial but appears to be associated with a decreased risk of ovarian cancer and no increase in the risk of breast cancer (II-2). 7.Combined oral contraceptive pills (COCs) are associated with a decreased risk of ovarian, endometrial, and colorectal cancers (II-2). A possible association has been shown between COC use and risk of cervical cancer (II-2), but causation has not been demonstrated. 8.A blood pressure measurement is the only examination and/or investigation that is required prior to initiating combined hormonal contraception (CHC) in women who are otherwise healthy by history (II-2). Baseline weight and body mass index assessment might be helpful for monitoring changes in CHC users. Pelvic examination, Pap test, screening for sexually transmitted infections, and thrombophilia screening are not required prior to initiating CHC (III). 9.Combined oral contraceptive pills and other combined hormonal contraception (CHC) can be started at any time during the menstrual cycle provided that pregnancy or the possibility of pregnancy can be reasonably ruled out. Where there is uncertainty, the benefits of starting CHC likely outweigh any risks (III). 10.Starting combined hormonal contraception immediately (Quick Start) may improve short-term compliance and is not associated with an increase in unscheduled bleeding or other side effects (I). 11.The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than 7 days, either by delaying the start of combined hormonal contraception (CHC) or by missing active hormone doses during the first or third weeks of CHC (I). Ovulation rarely occurs after 7 consecutive days of CHC use (II-2). 12.Emergency contraception (EC) and back-up contraception may be required in some instances of missed combined hormonal contraception (CHC), particularly when the hormone-free interval has exceeded 7 days. EC is rarely indicated for missed CHC in the second or third week of the cycle unless there are repeated omissions or failure to use back-up contraception after the missed doses (III). 13.Combined oral contraceptive pill exposure just prior to or during pregnancy is not associated with an increased risk of major birth defects (II-2). 14.The effectiveness of combined hormonal contraception (CHC), including combined oral contraceptive pills, may be affected by other medications, including but not limited to some anticonvulsants, some antiretrovirals, rifampicin, and griseofulvin. CHCs may affect the serum levels of other medications, including some anticonvulsants and antiretrovirals (II-2). 15.The contraceptive patch may be less effective in women with a body weight ≥90 kg (II-2). 16.Compared with the combined oral contraceptive pill, transdermal contraceptive patch use is associated with less breakthrough bleeding and spotting but more breast discomfort or pain, nausea and vomiting, and dysmenorrhea (I). 17.Pharmacokinetic studies indicate that serum hormone concentrations of ethinyl estradiol and norelgestromin are maintained at ovulation inhibitory levels throughout at least 9 days of continuous transdermal contraceptive patch wear (II-2). 18.The vaginal contraceptive ring is associated with less unscheduled bleeding than the combined oral contraceptive pill and the duration of menstrual bleeding is significantly shorter than that seen with the contraceptive patch (I). 19.Serum levels of ethinyl estradiol and etonorgestrel are maintained at ovulation inhibitory levels for at least 28 days after the vaginal contraceptive ring has been inserted (II-2). 20.Continuous and/or extended regimens of combined hormonal contraception (CHCs) have similar rates of adherence and effectiveness compared with 28-day cyclic CHC regimens (I). 21.Continuous and/or extended (C/E) regimens of combined hormonal contraception (CHC) are associated with significantly less menstruation-associated symptoms than are cyclic CHC (I). Bleeding and/or spotting with C/E CHC regimens decreases with each successive cycle and is similar to or less than that with cyclic CHC (I). Recommendations 1.Health care providers should give clear instructions for hormonal contraceptive use, including how to manage missed hormonal contraception, as part of contraceptive counselling. Women should be provided with resources to refer to in the event of missed and/or delayed hormonal contraceptives or if they develop any signs of a serious adverse event while using hormonal contraception (III-A). 2.Health care providers should consider advising women who are initiating contraception to start their combined hormonal contraception (CHC) immediately (Quick Start) provided that they are reasonably certain that the woman is not pregnant. Back-up contraception (barrier method) or abstinence should be used for the first 7 consecutive days of CHC use unless CHC was initiated on the first day of menses (I-A). 3.Health care providers should consider the possibility of irregular pill taking, concomitant medication use, malabsorption, uterine or cervical pathology, pregnancy, or chlamydial infection in women presenting with persistent unscheduled bleeding on the combined oral contraceptive pill (III-A). 4.If 1 combined oral contraceptive pill or other combined hormonal contraception (CHC) method is missed in the first week of use, back-up contraception or abstinence should be used until the CHC method has been used for 7 consecutive days. In the case of missed CHC in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle (III-A). 5.Back-up contraception should be used when 3 or more consecutive doses/days of combined hormonal contraception (CHC) have been missed in the second or third week of hormone use until the CHC has been used for 7 consecutive days. For practical reasons, the scheduled hormone-free interval should be eliminated in these cycles (I-A). 6.Health care providers should be aware of other medications being used by combined hormonal contraception users and the possibility of drug interactions that could affect serum levels and effectiveness of either medication (II-2A). 7.Health care professionals should be aware of the option of using continuous and/or extended combined hormonal contraception regimens and consider offering them to women for contraception, medical reasons, and personal preferences (III-A). 8.Women using continuous and/or extended combined hormonal contraception regimens should be counselled about expected bleeding patterns and how to manage unscheduled bleeding or spotting (III-A). 9.When a specific product has been prescribed to a woman, she should be informed if a generic substitution is being considered and her health care provider should be advised if a substitution is made. The woman should have the option to agree or disagree to the substitution and be informed about any difference in cost for a specific product (III-B).

Objectif Mettre a la disposition des fournisseurs de soins des lignes directrices concernant le recours a des methodes contraceptives pour prevenir la grossesse et la promotion d'une sexualite saine. Issues Efficacite globale des methodes contraceptives citees : evaluation de l'innocuite, des effets indesirables et de la baisse du taux de grossesse; effet des methodes contraceptives citees sur la sante sexuelle et le bien-etre general; disponibilite des methodes contraceptives citees au Canada. ReSULTATS: Des recherches ont ete effectuees dans MEDLINE et la base de donnees Cochrane afin d'en tirer les articles en anglais publies entre janvier 1994 et decembre 2015 traitant de sujets lies a la contraception, a la sexualite et a la sante sexuelle, dans le but de mettre a jour le consensus canadien sur la contraception paru de fevrier a avril 2004. Nous avons egalement passe en revue les publications pertinentes du gouvernement canadien, ainsi que les declarations de principes issues d'organisations competentes vouees a la sante et a la planification familiale. Valeurs La qualite des resultats a ete evaluee au moyen des criteres decrits par le Groupe d'etude canadien sur les soins de sante preventifs. Les recommandations quant a la pratique sont classees en fonction de la methode decrite dans le rapport du Groupe. DeCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Background: Absent or reversed end-diastolic flow velocity (ARED) in the umbilical arteries is typically associated with severe intrauterine growth restriction (IUGR), although there may be other causes, such as aneuploidy. Case: A healthy 30-year-old gravida 2, para 0 woman with an uneventful pregnancy and normal prenatal screening test results presented with sudden cessation of fetal movement at 26 weeks' gestation. Ultrasound demonstrated unexplained AIRED with normal fetal growth and normal amniotic fluid volume. The fetus died during transfer to the labour and delivery unit. The cause of fetal demise was initially assumed to be feto-maternal hemorrhage, but postmortem examination revealed non-compaction of the ventricular myocardium. Conclusion: Intrinsic myocardial disease should be considered in the differential diagnosis when AIRED is discovered in the umbilical arteries, especially when fetal growth is normal. Postmortem examination should be performed even if a prior 18- to 20-week anatomical ultrasound has been reported as normal.

OBJECTIVE To provide guidelines for health-care providers on the use of contraceptive methods to prevent pregnancy and sexually transmitted diseases. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, risk of infection, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the cost and availability of cited contraceptive methods in Canada. EVIDENCE Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1988 to March 2003, in order to update the Report of the Consensus Committee on Contraception published in May-July 1998. Relevant Canadian Government publications and position papers from appropriate health and family planning organizations were also reviewed. VALUES The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice are ranked according to the method described in this Report.

To provide guidelines for health-care providers on the use of contraceptive methods to prevent pregnancy and sexually transmitted diseases.Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, risk of infection, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the cost and availability of cited contraceptive methods in Canada.Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1988 to March 2003, in order to update the Report of the Consensus Committee on Contraception published in May-July 1998. Relevant Canadian Government publications and position papers from appropriate health and family planning organizations were also reviewed.The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice are ranked according to the method described in this Report.