Visualizing indoor ozone exposures via o-dianisidine based colorimetric passive sampler

In this study, we developed a colorimetric ozone passive sampler (OPS) incorporating o-dianisidine, a redox dye, into a polydimethylsiloxane sheet. The reaction between ozone (O3) and o-dianisidine result in a visible yellowish color change. Unlike previous passive methods that rely on nitrate extraction or the color disappearance of indigotrisulfonate, the OPS offered improved recognition of average O3 exposure. To optimize OPS based on time-weighted average (TWA), we extracted and quantified the amount of reacted o-dianisidine after exposing OPS to O3 by varying concentrations (0-200 ppb) within 8 h. Colorimetric changes of OPS were further analyzed by capturing images, and the effective absorbance of blue scale showed the best fit (EAB, R2 =0.997). OPS validation on visual detection assessed by six parameters: limit of detection, limit of quantification, reproducibility, sampling rate, selectivity to interfering gases, and sensitivity to environmental factors. To enhance visibility, the OPS was assembled with coloration exposure guidelines, and a smartphone app was developed to quantify average O3 exposures. We further conducted field tests that showed the significant disparity between O3 concentrations and personal O3 exposures, which is considered more crucial for assessing health risks. The OPS was optimized to monitor O3 exposure levels and raise awareness among workers and occupants regarding invisible indoor hazards.

Hysteroscopic suture of levonorgestrel-releasing intrauterine system: learning curve for in vitro simulation training

OBJECTIVE

To simulate hysteroscopic suturing in vitro and analyze the learning curve of gynecologists with different experience levels.

METHODS

Three gynecologists were trained on uterine models in a circulating water box. The posterior uterine wall was sutured 10 times under hysteroscopy for 5 consecutive days, and the time of each suture procedure was recorded.

RESULTS

Doctors A, B, and C completed 50 posterior uterine sutures. After Dr. C completed 50 sutures on the posterior wall, he added 50 sutures on the anterior wall (Group D). The mean suturing time was 71.54 ± 68.158 s in Group A, 50.10 ± 28.060 s in Group B, 34.04 ± 10.457 s in Group C, and 30.38 ± 8.734 s in Group D. The difference between Groups C and B and between Groups B and A was statistically significant. There was no statistically significant difference between Groups C and D. Simulation curves were created using the number of features as the abscissa and cumulative sum as the coordinate, with peak curves of 19, 27, and 18 cases for Group A, B, and C, respectively.

CONCLUSION

Doctors with experience in single-hole laparoscopic surgery or hysteroscopic suture surgery can significantly shorten the hysteroscopic suturing time.

Development and validation of an expanded panel of progestins using liquid chromatography-tandem triple quadrupole mass spectrometry to monitor protocol compliance in hormonal contraceptive pharmacokinetic/pharmacodynamic studies

We developed and validated the use of ultra-high-performance liquid chromatography-heated electrospray ionization-tandem triple quadrupole mass spectrometry to simultaneously analyze serum concentrations of ethinylestradiol, dienogest, norelgestromin, norethindrone, gestodene, levonorgestrel, etonogestrel, segesterone acetate, medroxyprogesterone acetate, and drospirenone. The calibration range for all targets was 0.009-10 ng/mL, with lower limit of quantification of 0.009 ng/mL for all analytes except gestodene (0.019 ng/mL). We used our assay to check compliance among participants in a clinical trial, confirmed the use of drospirenone in 11 of 13 study participants, and evidence of noncompliant progestins in 2 (levonorgestrel = 1, norethindrone = 1). We conclude that this approach provides an accurate method to check protocol compliance in contraceptive clinical trials. IMPLICATIONS: The availability of a liquid chromatography-tandem triple quadrupole mass spectrometry multiprogestin analysis panel for simultaneous evaluation of the most common contraceptive steroids approved worldwide could improve monitoring of compliance and protocol adherence in clinical trials.

Understanding temporal changes and seasonal variations in glycemic trends using wearable data

Seasonal variations in glycemic trends remain largely unstudied despite the growing prevalence of diabetes. To address this gap, our objective is to investigate temporal changes in glycemic trends by analyzing intensively sampled blood glucose data from 137 patients (ages 2 to 76, primarily type 1 diabetes) over the course of 9 months to 4.5 years. From over 91,000 days of continuous glucose monitor data, we found that glycemic control decreases significantly around the holidays, with the largest decline observed on New Year's Day among the patients with already poor glycemic control (i.e., <55% time in the target range). We also observed seasonal variations in glycemic trends, with patients having worse glycemic control in the months of November to February (i.e., mid-fall and winter, in the United States), and better control in the months of April to August (i.e., mid-spring and summer). These insights are critical to inform targeted interventions that can improve diabetes outcomes.

Oral emergency contraception with levonorgestrel plus piroxicam: a randomised double-blind placebo-controlled trial

BACKGROUND

Levonorgestrel, a standard drug for emergency contraception (EC), is not effective if administered post-ovulation. A cyclo-oxygenase inhibitor could contribute synergistic effects. We investigated whether a single 40 mg oral dose of piroxicam as co-treatment with levonorgestrel improved emergency contraceptive efficacy.

METHODS

This was a randomised double-blind placebo-controlled trial carried out in a major community sexual and reproductive health service in Hong Kong. Women who required levonorgestrel EC within 72 h of unprotected sexual intercourse were recruited and block-randomised in a 1:1 ratio to receive a single supervised dose of levonorgestrel 1·5 mg plus either piroxicam 40 mg or placebo orally. Group assignment was concealed in opaque envelopes and masked to the women, clinicians, and investigators. At follow-up 1-2 weeks after the next expected period, the pregnancy status was noted by history or pregnancy test. The primary efficacy outcome was the proportion of pregnancies prevented out of those expected based on an established model. All women randomised to receive the study drug and who completed the follow-up were analysed. The trial was registered with ClinicalTrials.gov, NCT03614494.

FINDINGS

860 women (430 in each group) were recruited between Aug 20, 2018, and Aug 30, 2022. One (0·2%) of 418 efficacy-eligible women in the piroxicam group were pregnant, compared with seven (1·7%) of 418 in the placebo group (odds ratio 0·20 [95% CI 0·02-0·91]; p=0·036). Levonorgestrel plus piroxicam prevented 94·7% of expected pregnancies compared with 63·4% for levonorgestrel plus placebo. We noted no significant difference between the two groups in the proportion of women with advancement or delay of their next period, or in the adverse event profile.

INTERPRETATION

Oral piroxicam 40 mg co-administered with levonorgestrel improved efficacy of EC in our study. Piroxicam co-administration could be considered clinically where levonorgestrel EC is the option of choice.

FUNDING

None.

Single-cycle influenza virus vaccine generates lung CD8+ Trm that cross-react against viral variants and subvert virus escape mutants

Influenza virus-specific tissue-resident memory (Trm) CD8+ T cells located along the respiratory tract provide cross-strain protection against a breadth of influenza viruses. We show that immunization with a single-cycle influenza virus vaccine candidate (S-FLU) results in the deposition of influenza virus nucleoprotein (NP)-specific CD8+ Trm along the respiratory tract that were more cross-reactive against viral variants and less likely to drive the development of cytotoxic T lymphocyte (CTL) escape mutants, as compared to the lung memory NP-specific CD8+ T cell pool established following influenza infection. This immune profile was linked to the limited inflammatory response evoked by S-FLU vaccination, which increased TCR repertoire diversity within the memory CD8+ T cell compartment. Cumulatively, this work shows that S-FLU vaccination evokes a clonally diverse, cross-reactive memory CD8+ T cell pool, which protects against severe disease without driving the virus to rapidly evolve and escape, and thus represents an attractive vaccine for use against rapidly mutating influenza viruses.

Effect of Maillard Reaction Products Derived from Cysteine on the Formation of Dimethyl Disulfide and Dimethyl Trisulfide during Storage

The effect of Maillard reaction products derived from cysteine on dimethyl disulfide (DMDS) and dimethyl trisulfide (DMTS) was evaluated in the ternary mixture (methionine, cysteine, and xylose) and binary mixture (methionine and 2-threityl-thiazolidine-4-carboxylic acid) during 56 days storage. Changes in concentrations revealed that the methionine/cysteine/xylose model showed lower concentrations of DMDS and DMTS than those of the binary mixture. Antioxidant ability and labeled isotopomer proportion information indicated that low levels of DMDS and DMTS in the ternary mixture were attributed to not only 2-furfurylthiol and 2-methyl-3-furanthiol (MFT) reacting with methanethiol but also the ternary mixture having stronger antioxidant activity. Correlation analysis demonstrated that MFT reacting with methanethiol and strong antioxidant ability are considered major factors controlling the formation of DMTS and DMDS, respectively. Research on the reaction mechanism of the rate-limiting step would provide the basis for preventing the development of DMDS and DMTS during storage.

Levonorgestrel Emergency Contraception Information Accuracy From West Virginia Community Pharmacies: A Mystery Caller Approach

BACKGROUND

To ensure access to effective levonorgestrel (LNG) emergency contraception (EC), pharmacies must keep medication in stock or available for quick delivery, and pharmacists must be knowledgeable about sales restrictions and the therapeutic window for EC. We conducted a mystery caller study to assess LNG EC availability and information accuracy provided by staff in West Virginia community pharmacies.

METHODS

A female research team member posed as a 16-year-old caller to ask pharmacy staff questions about whether LNG EC was in stock, the requirements for purchase, and when it should be taken for effectiveness. Data were analyzed with SPSS using the Pearson's χ2 test to determine if there was a relationship between pharmacy type and response accuracy to our questions about point-of-sale requirements and timing for effectiveness for LNG EC.

RESULTS

Of the 506 pharmacies in the sample, 275 (54.3%) were chain pharmacies and 231 (45.7%) were independent. Overall, chain pharmacies provided significantly more accurate answers than independent pharmacies on all point-of-sale requirements. Regarding timing for effectiveness, 49.2% of all pharmacies provided an accurate response (62.9% for chain pharmacies vs. 32.9% for independent pharmacies).

CONCLUSIONS

Overall, availability and accuracy regarding LNG EC were poor in West Virginia pharmacies. Pharmacists, particularly those at independent pharmacies serving rural communities, are in a critical and powerful position to influence community health by providing accurate and timely information and access to all contraceptive options, including LNG EC.

Risks of Uterine Perforation and Expulsion Associated With Intrauterine Devices

OBJECTIVE

The APEX-IUD (Association of Perforation and Expulsion of Intrauterine Devices) study evaluated the association of postpartum timing of intrauterine device (IUD) insertion, breastfeeding, heavy menstrual bleeding, and IUD type (levonorgestrel-releasing vs copper) with risks of uterine perforation and IUD expulsion in usual clinical practice. We summarize the clinically important findings to inform counseling and shared decision making.

METHODS

APEX-IUD was a real-world (using U.S. health care data) retrospective cohort study of individuals aged 50 years and younger with IUD insertions between 2001 and 2018 and with electronic health record data. Cumulative incidences of uterine perforation and IUD expulsion were calculated. Adjusted hazard ratios (aHRs) and 95% CIs were estimated from proportional hazards models with control of confounding.

RESULTS

Among the study population of 326,658, absolute risk of uterine perforation was low overall (cumulative incidence, 0.21% [95% CI 0.19-0.23%] at 1 year and 0.61% [95% CI 0.56-0.66% at 5 years]) but was elevated for IUDs inserted during time intervals within 1 year postpartum, particularly among those between 4 days and 6 weeks postpartum (aHR 6.71, 95% CI 4.80-9.38), relative to nonpostpartum insertions. Among postpartum insertions, IUD expulsion risk was greatest for insertions in the immediate postpartum period (0-3 days after delivery) compared with nonpostpartum (aHR 5.34, 95% CI 4.47-6.39). Postpartum individuals who were breastfeeding had a slightly elevated risk of perforation and lowered risk of expulsion than those not breastfeeding. Among nonpostpartum individuals, those with a heavy menstrual bleeding diagnosis were at greater risk of expulsion than those without (aHR 2.84, 95% CI 2.66-3.03); heavy menstrual bleeding also was associated with a slightly elevated perforation risk. There was a slightly elevated perforation risk and slightly lower expulsion risk associated with levonorgestrel-releasing IUDs compared with copper IUDs.

CONCLUSION

Absolute risk of adverse outcomes with IUD insertion is low. Clinicians should be aware of the differences in risks of uterine perforation and expulsion associated with IUD insertion during specific postpartum time periods and with a heavy menstrual bleeding diagnosis. This information should be incorporated into counseling and decision making for patients considering IUD insertion.

FUNDING SOURCE

Bayer AG.

CLINICAL TRIAL REGISTRATION

EU PAS register, EUPAS33461.

Levonorgestrel intrauterine device use and incident idiopathic intracranial hypertension among commercially insured women

OBJECTIVES

To estimate the hazard of incident idiopathic intracranial hypertension, a potentially blinding condition, among women using levonorgestrel intrauterine devices (LNG-IUD) compared to copper IUD, as conflicting associations have been reported.

STUDY DESIGN

This retrospective, longitudinal cohort study identified women ages 18-45 years in a large care network (January 1, 2001, to December 31, 2015) using LNG-IUD, subcutaneous etonogestrel implant, copper IUD, tubal device/surgery, or hysterectomy. Incident idiopathic intracranial hypertension was defined as the first diagnosis code for after 1 year without any codes and following brain imaging or lumbar puncture. Kaplan-Meier analysis estimated time-dependent probabilities of idiopathic intracranial hypertension at 1 and 5 years after incident contraception use, stratified by type. Cox regression estimated the hazard of idiopathic intracranial hypertension associated with LNG-IUD use compared to copper IUD (primary comparison) after adjusting for sociodemographics and factors associated with idiopathic intracranial hypertension (e.g., obesity) or contraception selection. A sensitivity analysis with propensity score-adjusted models was performed.

RESULTS

Of 268,280 women, 78,175 (29%) used LNG-IUD, 8715 (3%) etonogestrel implant, 20,275 (8%) copper IUD, 108,216 (40%) hysterectomy, 52,899 (20%) tubal device/surgery, and 208 (0.08%) developed idiopathic intracranial hypertension over a mean follow-up of 2.4 ± 2.4 years. Also, 1-/5-year Kaplan-Meier idiopathic intracranial hypertension probabilities were 0.0004/0.0021 for LNG-IUD and 0.0005/0.0006 for copper IUD users. LNG-IUD use did not show significantly different hazard of idiopathic intracranial hypertension compared to copper IUD (adjusted hazard ratio 1.84 [95% CI 0.88, 3.85]). Sensitivity analyses were similar.

CONCLUSIONS

We did not observe a significantly increased hazard of idiopathic intracranial hypertension among women using LNG-IUD compared to copper IUDs.

IMPLICATIONS

The lack of an association between LNG-IUD use and idiopathic intracranial hypertension in this large observational study provides reassurance to women considering initiation or continued use of this highly effective contraceptive method.

Levonorgestrel Implant Continuation among Postpartum Women Admitted to the Department of Obstetrics and Gynecology of a Tertiary Care Centre

Introduction

Jadelle (Levonorgestrel) implant is a long-acting reversible contraceptives which is recommended for post-partum contraceptive device due to their high efficacy, convenience, and cost-effectiveness. The continuation of Jadelle implant prevents unintended pregnancies and maintain healthy spacing between the pregnancies, thus improving maternal and child health outcomes. However, Government has endorsed the long-acting reversible contraceptives as immediate post-partum contraception, the status of Jadelle implant continuity is unknown. The aim of this study was to find out the prevalence of levonorgestrel implant continuation among postpartum women admitted to the Department of Obstetrics and Gynecology of a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among women who had Jadelle implant inserted within 48 hours of delivery admitted to the Department of Obstetrics and Gynecology at a tertiary care centre. Ethical approval was taken from the Institutional Review Committee. Data from 1 July 2020 to 31 December 2020 were collected between 1 July 2022 to 31 December 2022 from the hospital records. Patients were interviewed after 2 years through phone calls. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Out of 157 post-partum women, 145 (92.36%) (88.20-96.52, 95% Confidence Interval) had levonorgestrel implant in-situ.

Conclusions

The prevalence of levonorgestrel implant continuation among postpartum women admitted to the Department of Obstetrics and Gynecology was similar to other studies done in similar settings.

Keywords

contraception; family planning; levonorgestrel; postpartum period; pregnancy.

Feasibility and Acceptability of LNG 1.5 mg as an On-Demand Pericoital Contraceptive in Ghana

Globally, there is a need for more family planning method options as currently, available options do not adequately meet the needs of women, specifically those who have infrequent sex. Levonorgestrel (LNG) 1.5 mg is widely available as emergency contraception pills (ECP), and recent research has shown that certain women take it as their main form of contraception. Furthermore, limited studies have found repeat, on-demand use safe and efficacious. This 12-month prospective, single-arm, interventional study in Ghana tested whether a single LNG 1.5 mg on-demand or pericoital ("around the time of sex") dose contraceptive was acceptable to women who have infrequent sex and if pharmacy provision was feasible. The study sample (1,890) comprised women of reproductive age recruited from urban areas, having infrequent sex (i.e., coital frequency ≤ 6× per month), and not using any other modern methods except condoms or ECP at the time of study inclusion. Results indicated that there is demand and acceptability for a pericoital pill and that pharmacy provision is feasible. Furthermore, precoital use of the pill had high levels of satisfaction and was popular with new users. Adding LNG 1.5 mg for pericoital use to the family planning method mix has the potential to address an important segment of the population currently underserved, decrease unwanted pregnancies, and increase modern contraceptive prevalence rates.

Hormonal contraception use and insomnia: A nested case-control study

Evidence is limited concerning possible associations between the use of hormonal contraception and insomnia. We applied the nested case-control design on a nationwide sample of women, aged 15-49 years, derived from national health care registries to characterize the association between the use of hormonal contraception and the occurrence of insomnia. There were altogether 294,356 users and 294,356 non-users of hormonal contraception. 11,105 new cases of insomnia emerged among the 1,148,969 person-years of the follow-up period of two years. All the significant associations of hormonal contraception with insomnia emerged among the participants aged 34 years or younger, and if only the tertiary care data was concerned, among the those aged 15-19 years. The users of the fixed combination of drospirenone and ethinylestradiol as well as that of cyproterone and ethinylestradiol had significantly decreased odds for insomnia, whereas the users levonorgestrel-releasing intrauterine devise as well as those of vaginal ring with etonogestrel and ethinylestradiol had significantly increased odds for insomnia as compared with non-users. Our findings suggest that different products prescribed for hormonal contraception may be differentially associated with the occurrence of insomnia.

The effects of type and workload of internal tasks on voluntary saccades in a target-distractor saccade task

When we engage in internally directed cognition, like doing mental arithmetic or mind wandering, fewer cognitive resources are assigned for other activities like reacting to perceptual input-an effect termed perceptual decoupling. However, the exact conditions under which perceptual decoupling occurs and its underlying cognitive mechanisms are still unclear. Hence, the present study systematically manipulated the task type (arithmetic, visuospatial) and workload (control, low, high) of the internal task in a within-subject design and tested its effects on voluntary saccades in a target-distractor saccade task. As expected, engagement in internal tasks delayed saccades to the target. This effect was moderated by time, task, and workload: The delay was largest right after internal task onset and then decreased, potentially reflecting the intensity of internal task demands. Saccades were also more delayed for the high compared to the low workload condition in the arithmetic task, whereas workload conditions had similarly high effects in the visuospatial task. Findings suggests that perceptual decoupling of eye behavior gradually increases with internal demands on general resources and that perceptual decoupling is specifically sensitive to internal demands on visuospatial resources. The latter may be mediated by interference due to eye behavior elicited by the internal task itself. Internal tasks did not affect the saccade latency-deviation trade-off, indicating that while the internal tasks delayed the execution of the saccade, the perception of the saccade stimuli and spatial planning of the saccade continued unaffected in parallel to the internal tasks. Together, these findings shed further light on the specific mechanisms underlying perceptual decoupling by suggesting that perceptual decoupling of eye behavior increases as internal demands on cognitive resources overlap more strongly with demands of the external task.

The FDA Declares Levonorgestrel a Nonabortifacient-A 50-Year Saga Takes a Decisive Turn

This Viewpoint discusses recent judicial developments and the newly-enunciated FDA position that levonorgestrel is a nonabortifacient.

How did regional lockdowns during the COVID-19 pandemic affect recruitment into a large multinational cohort study of intrauterine device users?

OBJECTIVES

To investigate the impact of lockdown policies on the recruitment of an ongoing cohort study.

STUDY DESIGN

We performed descriptive analyses of recruitment, dropout, and baseline characteristics over time. Oxford Stringency Index was used to assess the impact of regional constraints on recruitment.

RESULTS

Drop in recruitment clearly reflected the Stringency Index within the first months of the pandemic. Unexpectedly, drop-out rates declined in 2020/2021. Baseline characteristics were comparable, yet younger women were recruited more frequently during the pandemic.

CONCLUSIONS

There was no strong evidence of recruitment bias due to the pandemic.

IMPLICATIONS

The COVID-19 pandemic is a potential source of bias for ongoing studies and its influence on the study conduct (e.g., recruitment, drop-out) should be thoroughly evaluated to ensure that study results are not biased in this regard. The Oxford's Government Stringency Index can be used to identify pandemic-affected time periods.

Forensic Nurses' Understanding of Emergency Contraception Mechanisms: Implications for Access to Emergency Contraception

BACKGROUND

An estimated 25,000 pregnancies result from sexual assault in the United States annually. Numerous professional healthcare organizations endorse offering emergency contraception (EC) as an integrated aspect of post-sexual-assault care. Lack of knowledge surrounding EC's mechanism of action, including misinterpreting ECs as abortifacients, might restrict patient access to this important healthcare option.

PURPOSE

We evaluated sexual assault nurse examiners' understanding of the mechanism of action of oral ECs levonorgestrel (LNG) and ulipristal acetate (UPA).

METHODS

A cross-sectional survey of practicing sexual assault nurse examiners was conducted through the International Association of Forensic Nurses.

RESULTS

Among 173 respondents, 96.53% reported they prescribed/dispensed EC at the time of medical forensic examinations. LNG was prescribed more frequently than UPA (57.80% vs. 38.2%, respectively). When asked if they agreed or disagreed if LNG and UPA can disrupt an established pregnancy, 83.2% selected disagree/strongly disagree for LNG versus 78.6% for UPA, which were not significantly different. When asked whether the Supreme Court ruling overturning Roe v. Wade would change their EC prescribing, 79.77% reported it will have no change, 6.94% said it would increase, and 12.72% reported they were unsure. Several commented they were concerned whether state laws would prohibit EC and at least one program stopped prescribing EC because of their state laws.

IMPLICATIONS

Addressing misinformation regarding EC's mechanism of action and increasing access to oral EC options after sexual assault have the potential to reduce the incidence of rape-related pregnancy.

Bioinspired helical-artificial fibrous muscle structured tubular soft actuators

Biological tubular actuators show diverse deformations, which allow for sophisticated deformations with well-defined degrees of freedom (DOF). Nonetheless, synthetic active tubular soft actuators largely only exhibit few simple deformations with limited and undesignable DOF. Inspired by 3D fibrous architectures of tubular muscular hydrostats, we devised conceptually new helical-artificial fibrous muscle structured tubular soft actuators (HAFMS-TSAs) with locally tunable molecular orientations, materials, mechanics, and actuation via a modular fabrication platform using a programmable filament winding technique. Unprecedentedly, HAFMS-TSAs can be endowed with 11 different morphing modes through programmable regulation of their 3D helical fibrous architectures. We demonstrate a single "living" artificial plant rationally structured by HAFMS-TSAs exhibiting diverse photoresponsive behaviors that enable adaptive omnidirectional reorientation of its hierarchical 3D structures in the response to environmental irradiation, resembling morphing intelligence of living plants in reacting to changing environments. Our methodology would be significantly beneficial for developing sophisticated soft actuators with designable and tunable DOF.

Pharmacokinetics of dose-adjusted levonorgestrel emergency contraception combined with efavirenz-based antiretroviral therapy or rifampicin-containing tuberculosis regimens

OBJECTIVES

To determine if double-dose levonorgestrel emergency contraception (EC) in combination with efavirenz or rifampicin, 2 drugs known to decrease levonorgestrel exposure, resulted in similar pharmacokinetics compared to standard-dose levonorgestrel EC without drug-drug interactions.

STUDY DESIGN

We conducted a phase 2, open-label, multicenter, partially randomized, 4 parallel group trial in pre-menopausal females ≥16 years old without an indication for EC and not on hormonal contraception. Participants on dolutegravir-based antiretroviral therapy (ART) received levonorgestrel 1.5 mg (control group); those on rifampicin-containing tuberculosis therapy received levonorgestrel 3 mg; those on efavirenz-based ART were randomized 1:2 to levonorgestrel 1.5 mg or 3 mg. Plasma was collected through 48 hours post-dose to assess levonorgestrel pharmacokinetics. Area under the concentration-time curve (AUC) over 8 hours was the primary outcome. Levonorgestrel pharmacokinetic parameters were compared between groups using geometric mean ratios (GMR) with 90% confidence intervals.

RESULTS

The median (Q1, Q3) age for all participants (n = 118) was 34 (27, 41) years and BMI was 23.2 (20, 26.3) kg/m2. Participants receiving levonorgestrel 1.5mg plus efavirenz (n = 17) had 50% lower AUC0-8h compared to the control group (n = 32) [0.50 (0.40, 0.62)]. Participants receiving levonorgestrel 3 mg had a similar AUC0-8h when receiving either efavirenz (n = 35) [0.99 (0.81, 1.20)] or rifampicin (n = 34) [1.16 (0.99, 1.36)] compared to control. Levonorgestrel 3 mg resulted in similar or higher maximum concentration with either efavirenz [1.17 (0.96, 1.41)] or rifampicin [1.27 (1.09, 1.49)] compared to the control group.

CONCLUSIONS

Doubling the dose of levonorgestrel EC successfully increased levonorgestrel exposure over the first 8 hours in participants receiving either efavirenz-based ART or rifampicin-containing tuberculosis therapy.

IMPLICATIONS

Adjusting levonorgestrel emergency contraception from 1.5 mg to 3 mg improves levonorgestrel pharmacokinetic exposure in participants receiving either efavirenz-based antiretroviral regimens or rifampicin-containing tuberculosis therapy. These data support guideline recommendations to double the dose of levonorgestrel emergency contraception in persons on medications that decrease levonorgestrel exposure by inducing levonorgestrel metabolism.

One-year pregnancy and continuation rates after placement of levonorgestrel or copper intrauterine devices for emergency contraception: a randomized controlled trial

BACKGROUND

Recent evidence demonstrates the effectiveness of the levonorgestrel 52-mg intrauterine device for emergency contraception vs the copper T380A intrauterine device. Of note, 1-year pregnancy and continuation rates after intrauterine device placement for emergency contraception remain understudied.

OBJECTIVE

This study compared 1-year pregnancy and intrauterine device continuation rates and reasons for discontinuation among emergency contraception users randomized to the levonorgestrel 52-mg intrauterine device or the copper intrauterine device.

STUDY DESIGN

This participant-masked, randomized noninferiority trial recruited emergency contraception individuals desiring an intrauterine device from 6 Utah family planning clinics between August 2016 and December 2019. Participants were randomized 1:1 to the levonorgestrel 52-mg intrauterine device group or the copper T380A intrauterine device group. Treatment allocation was revealed to participants at the 1-month follow-up. Trained personnel followed up the participants by phone, text, or e-mail at 5 time points in 1 year and reviewed electronic health records for pregnancy and intrauterine device continuation outcomes for both confirmation and nonresponders. We assessed the reasons for the discontinuation and used Cox proportional-hazard models, Kaplan-Meier estimates, and log-rank tests to assess differences in the continuation and pregnancy rates between the groups.

RESULTS

The levonorgestrel and copper intrauterine device groups included 327 and 328 participants, respectively, receiving the respective interventions. By intention-to-treat analysis at 1 year, the pregnancy rates were similar between intrauterine device types (2.8% [9/327] in levonorgestrel 52-mg intrauterine device vs 3.0% [10/328] in copper intrauterine device; risk ratio, 0.9; 95% confidence interval, 0.4-2.2; P=.82). Most pregnancies occurred in participants after intrauterine device removal, with only 1 device failure in each group. Of note, 1-year continuation rates did not differ between groups with 204 of 327 levonorgestrel 52-mg intrauterine device users (62.4%) and 183 of 328 copper T380A intrauterine device users (55.8%) continuing intrauterine device use at 1 year (risk ratio, 1.1; 95% confidence interval, 1.0-1.2; P=.09). There were differences concerning the reasons for discontinuation between intrauterine device types, with more bleeding and cramping cited among copper intrauterine device users.

CONCLUSION

The pregnancy rates were low and similar between intrauterine device types. Of note, 6 of 10 intrauterine device emergency contraception users continued use at 1 year. Moreover, 1-year continuation rates were similar between intrauterine device types.

Contraception

This article outlines the basics of all contraceptive options available in the United States, providing providers necessary information to best provide equitable contraceptive care for women. Long-acting reversible contraception should be considered in all women as there are few contraindications to use. Levonorgestrel intrauterine devices have been found to be safe for use for longer periods of time, in some cases up to eight years. Combination hormone contraceptives remain popular and offer benefits beyond contraception; importantly newer formulations exist providing patients with more contraceptive options. Education regarding emergency contraception should be provided to all patients.

Levonorgestrel-releasing intrauterine system-based therapies for early-stage endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of studies evaluating the oncological and fertility outcomes of early-stage endometrial cancer (EC) treated with the levonorgestrel-releasing intrauterine system (LIUS)-based regimens.

METHODS

The Meta-analyses Of Observational Studies in Epidemiology statement for meta-analyses was followed. Searches were conducted on MEDLINE, Embase, PubMed, Preprints, and the Cochrane Central Register of Controlled Trials from January 1990 to August 4, 2022. The Joanna Briggs Institute Critical Appraisal Checklist was used for quality assessment. The primary endpoint was the complete response (CR) rate and the secondary endpoints were relapse, pregnancy, and live birth rate.

RESULTS

A total of 25 studies (821 women) were included. The CR rate of LIUS-based regimens was 63.4% (95% confidence interval [CI]=52.3%-73.2%), with 29.6% (95% CI=23.3%-36.8%) of cases experiencing recurrence during follow-up. In sensitivity analyses, patients younger than 45 years of age with a body mass index <30 kg/m² who were treated with LIUS-based regimens achieved a high CR rate of 84.6% (95% CI=80.3%-88.1%) over a median follow-up of more than 24 months. Overall pregnancy and live birth rates were 37.9% (95% CI=24.1%-53.9%) and 39.3% (95% CI=24.0%-57.0%), respectively. No statistical differences were apparent in CR or relapse rates among the LIUS+GnRH agonist, LIUS+oral progesterone, or hysteroscopic resection followed by LIUS subgroups.

CONCLUSION

LIUS-based therapies are viable for the conservative management of early-stage endometrioid EC on CR and fertility outcome.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42022352890.