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Kaiser JE, Turok DK, Gero A, Gawron LM, Simmons RG, Sanders JN. One-year pregnancy and continuation rates after placement of levonorgestrel or copper intrauterine devices for emergency contraception: a randomized controlled trial. Am J Obstet Gynecol 2023; 228:438.e1-438.e10. [PMID: 36427600 PMCID: PMC10065890 DOI: 10.1016/j.ajog.2022.11.1296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Jennifer E Kaiser
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
| | - David K Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Alexandra Gero
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Lori M Gawron
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Rebecca G Simmons
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Jessica N Sanders
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
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Ceulemans M, Brughmans M, Poortmans LL, Spreuwers E, Willekens J, Roose N, De Wulf I, Foulon V. Development and Pilot Testing of a Dispensing Protocol on Emergency Contraceptive Pills for Community Pharmacists in Belgium. PHARMACY 2022; 10:pharmacy10030058. [PMID: 35736773 PMCID: PMC9228420 DOI: 10.3390/pharmacy10030058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022] Open
Abstract
Community pharmacists in Belgium frequently dispense emergency contraceptive pills (ECPs). However, variable and insufficient counseling practices exist across pharmacies, highlighting the need for standardization and quality improvement strategies. The aim of this project was to develop and test an ECP dispensing protocol for pharmacists. An ‘experience-based’ co-design approach involving academic and practicing pharmacists was applied, followed by a 4-month test period and interviews to assess users’ experiences. In total, eight geographically dispersed pharmacies participated. Pharmacists (n = 15) reached a consensus on most items to be included in the protocol, which was subsequently tested in seven pharmacies, with overall 97 registered ECP conversations. Pharmacists considered the protocol complete but felt that not all items should be mentioned/questioned during all conversations. They suggested only subtle modifications to be made prior to delivering a final protocol ready for nationwide distribution. Despite attributing positive effects to having a protocol, no single pharmacist ‘actively’ used it at-the-counter but used it instead as a ‘checklist’ after the encounter. Pharmacists found that the paper-based format of the protocol hindered protocol-based dispensing. Future research is needed to provide evidence on the actual benefits of protocol application, as well as to identify factors influencing the implementation of ECP dispensing using a software-integrated protocol.
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Affiliation(s)
- Michael Ceulemans
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (N.R.); (V.F.)
- Teratology Information Service, Netherlands Pharmacovigilance Centre Lareb, 5237 MH Hertogenbosch, The Netherlands
- L-C&Y, Child and Youth Institute, KU Leuven, 3000 Leuven, Belgium
- Correspondence: ; Tel.: +32-16-37-72-27
| | - Marieke Brughmans
- Faculty of Pharmaceutical Sciences, KU Leuven, 3000 Leuven, Belgium; (M.B.); (L.-L.P.); (E.S.); (J.W.)
| | - Laura-Lien Poortmans
- Faculty of Pharmaceutical Sciences, KU Leuven, 3000 Leuven, Belgium; (M.B.); (L.-L.P.); (E.S.); (J.W.)
| | - Ellen Spreuwers
- Faculty of Pharmaceutical Sciences, KU Leuven, 3000 Leuven, Belgium; (M.B.); (L.-L.P.); (E.S.); (J.W.)
| | - Julie Willekens
- Faculty of Pharmaceutical Sciences, KU Leuven, 3000 Leuven, Belgium; (M.B.); (L.-L.P.); (E.S.); (J.W.)
| | - Nele Roose
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (N.R.); (V.F.)
| | | | - Veerle Foulon
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (N.R.); (V.F.)
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Hepplewhite J, Ismail MA. Continuation of post-coital intrauterine contraceptive devices beyond index cycle at Sexual Health Sheffield. SEXUAL & REPRODUCTIVE HEALTHCARE 2022; 32:100730. [PMID: 35490481 DOI: 10.1016/j.srhc.2022.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/17/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
We aimed to observe the continuation of Emergency IUD beyond the index cycle and reasons for removal. We analysed data from the patients' electronic records of fifty consecutive women who had an IUD fitted at Sexual Health Sheffield for emergency contraception. 48 (96%) women continued with the IUD beyond the index cycle and 31 (62%) women for more than 1 year. Heavy menstrual bleeding, dysmenorrhoea and pain were the most frequent reasons cited for removal.
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Cheung TS, Goldstuck ND, Gebhardt GS. The intrauterine device versus oral hormonal methods as emergency contraceptives: A systematic review of recent comparative studies. SEXUAL & REPRODUCTIVE HEALTHCARE 2021; 28:100615. [PMID: 33799166 DOI: 10.1016/j.srhc.2021.100615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 12/01/2022]
Abstract
Oral emergency contraceptives do not appear to be as effective as the copper IUD as an emergency contraceptive. There is as yet no estimation of the relative efficacy rates rather than the failure rates. The references for this study were obtained by entering the terms "intrauterine device" "and "emergency contraception" in Medline, PubMed, Popline, Global Health and ClinicalTrials.gov. Chinese references were obtained from the Wanfang database. For the short term study articles with a defined population who were followed up after the index cycle were eligible. Women who were adequately followed for at least 6 months were included in the long term study. There were 13(of 228) studies which met our selection criteria and were conducted between August 2011 and January 2019. There were 960 insertions of four types of copper IUD with a failure rate of 0.104%. There were 22 failures out of 1453 oral emergency contraception users with a failure rate of 1.51%. The relative risk of failure for an intrauterine device versus an oral method was 0.1376(95% CI -0.03-0.58). The 6 month to 12 month pregnancy rate was 0-6% for IUDs and 2.7-12% for oral methods. The copper IUD appears to be more effective than oral methods as an emergency contraceptive. The 6 to 12 month pregnancy rates after using either method is 4-10%. Emergency contraception is not a solution to unintended pregnancy.
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Affiliation(s)
- Tik Shan Cheung
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Francie van Zyl Dr, Tygerberg Hospital, Bellville, Cape Town 7505, South Africa
| | - Norman D Goldstuck
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Francie van Zyl Dr, Tygerberg Hospital, Bellville, Cape Town 7505, South Africa.
| | - Gabriel S Gebhardt
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Francie van Zyl Dr, Tygerberg Hospital, Bellville, Cape Town 7505, South Africa
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Goldstuck ND, Cheung TS. The efficacy of intrauterine devices for emergency contraception and beyond: a systematic review update. Int J Womens Health 2019; 11:471-479. [PMID: 31686919 PMCID: PMC6709799 DOI: 10.2147/ijwh.s213815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/01/2019] [Indexed: 11/23/2022] Open
Abstract
Background The copper intrauterine device (IUD) is a very effective form of emergency contraception. The failure rate is about 0.1%. IUDs are also very cost-effective when used as long acting-reversible contraception (LARC). The purpose of this review is to attempt to confirm these findings. Methods The references for this study were generated by entering the terms “intrauterine device” and “emergency contraception” in Medline, PubMed, Popline, Global Health and ClinicalTrials.gov. Chinese references were obtained from the Wanfang database. For the emergency contraception study, articles with a defined population who were followed up until outcome were eligible. Women who were adequately followed for at least 6 months were included in the long term arm of the study. Results There were 18 (of 228) studies which met our selection criteria and were conducted in five countries, between August 2011 and January 2018. There were 1720 insertions of seven types of copper IUD with a failure rate of 0.12%. The maximum time from intercourse to IUD insertion was 14 days. The discontinuation rate at 12 months was over 20% in the long term studies. Conclusion There are now a combined total of 8550 reported insertions from two reviews with 8 pregnancies and a failure rate of 0.093%. Copper IUDs remain an effective form of emergency contraception, for which they are under-promoted. The major limitation of the studies is the lack of data relating unprotected intercourse to the day of the cycle.
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Affiliation(s)
- Norman D Goldstuck
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town 7505, South Africa
| | - Tik Shan Cheung
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Cape Town 7505, South Africa
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FSRH Guideline (April 2019) Overweight, Obesity and Contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:1-69. [PMID: 31053605 DOI: 10.1136/bmjsrh-2019-ooc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Abstract
BACKGROUND Emergency contraception (EC) is using a drug or copper intrauterine device (Cu-IUD) to prevent pregnancy shortly after unprotected intercourse. Several interventions are available for EC. Information on the comparative effectiveness, safety and convenience of these methods is crucial for reproductive healthcare providers and the women they serve. This is an update of a review previously published in 2009 and 2012. OBJECTIVES To determine which EC method following unprotected intercourse is the most effective, safe and convenient to prevent pregnancy. SEARCH METHODS In February 2017 we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Popline and PubMed, The Chinese biomedical databases and UNDP/UNFPA/WHO/World Bank Special Programme on Human Reproduction (HRP) emergency contraception database. We also searched ICTRP and ClinicalTrials.gov as well as contacting content experts and pharmaceutical companies, and searching reference lists of appropriate papers. SELECTION CRITERIA Randomised controlled trials including women attending services for EC following a single act of unprotected intercourse were eligible. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary review outcome was observed number of pregnancies. Side effects and changes of menses were secondary outcomes. MAIN RESULTS We included 115 trials with 60,479 women in this review. The quality of the evidence for the primary outcome ranged from moderate to high, and for other outcomes ranged from very low to high. The main limitations were risk of bias (associated with poor reporting of methods), imprecision and inconsistency.Comparative effectiveness of different emergency contraceptive pills (ECP)Levonorgestrel was associated with fewer pregnancies than Yuzpe (estradiol-levonorgestrel combination) (RR 0.57, 95% CI 0.39 to 0.84, 6 RCTs, n = 4750, I2 = 23%, high-quality evidence). This suggests that if the chance of pregnancy using Yuzpe is assumed to be 29 women per 1000, the chance of pregnancy using levonorgestrel would be between 11 and 24 women per 1000.Mifepristone (all doses) was associated with fewer pregnancies than Yuzpe (RR 0.14, 95% CI 0.05 to 0.41, 3 RCTs, n = 2144, I2 = 0%, high-quality evidence). This suggests that if the chance of pregnancy following Yuzpe is assumed to be 25 women per 1000 women, the chance following mifepristone would be between 1 and 10 women per 1000.Both low-dose mifepristone (less than 25 mg) and mid-dose mifepristone (25 mg to 50 mg) were probably associated with fewer pregnancies than levonorgestrel (RR 0.72, 95% CI 0.52 to 0.99, 14 RCTs, n = 8752, I2 = 0%, high-quality evidence; RR 0.61, 95% CI 0.45 to 0.83, 27 RCTs, n = 6052, I2 = 0%, moderate-quality evidence; respectively). This suggests that if the chance of pregnancy following levonorgestrel is assumed to be 20 women per 1000, the chance of pregnancy following low-dose mifepristone would be between 10 and 20 women per 1000; and that if the chance of pregnancy following levonorgestrel is assumed to be 35 women per 1000, the chance of pregnancy following mid-dose mifepristone would be between 16 and 29 women per 1000.Ulipristal acetate (UPA) was associated with fewer pregnancies than levonorgestrel (RR 0.59; 95% CI 0.35 to 0.99, 2 RCTs, n = 3448, I2 = 0%, high-quality evidence).Comparative effectiveness of different ECP dosesIt was unclear whether there was any difference in pregnancy rate between single-dose levonorgestrel (1.5 mg) and the standard two-dose regimen (0.75 mg 12 hours apart) (RR 0.84, 95% CI 0.53 to 1.33, 3 RCTs, n = 6653, I2 = 0%, moderate-quality evidence).Mid-dose mifepristone was associated with fewer pregnancies than low-dose mifepristone (RR 0.73; 95% CI 0.55 to 0.97, 25 RCTs, n = 11,914, I2 = 0%, high-quality evidence).Comparative effectiveness of Cu-IUD versus mifepristoneThere was no conclusive evidence of a difference in the risk of pregnancy between the Cu-IUD and mifepristone (RR 0.33, 95% CI 0.04 to 2.74, 2 RCTs, n = 395, low-quality evidence).Adverse effectsNausea and vomiting were the main adverse effects associated with emergency contraception. There is probably a lower risk of nausea (RR 0.63, 95% CI 0.53 to 0.76, 3 RCTs, n = 2186 , I2 = 59%, moderate-quality evidence) or vomiting (RR 0.12, 95% CI 0.07 to 0.20, 3 RCTs, n = 2186, I2 = 0%, high-quality evidence) associated with mifepristone than with Yuzpe. levonorgestrel is probably associated with a lower risk of nausea (RR 0.40, 95% CI 0.36 to 0.44, 6 RCTs, n = 4750, I2 = 82%, moderate-quality evidence), or vomiting (RR 0.29, 95% CI 0.24 to 0.35, 5 RCTs, n = 3640, I2 = 78%, moderate-quality evidence) than Yuzpe. Levonorgestrel users were less likely to have any side effects than Yuzpe users (RR 0.80, 95% CI 0.75 to 0.86; 1 RCT, n = 1955, high-quality evidence). UPA users were more likely than levonorgestrel users to have resumption of menstruation after the expected date (RR 1.65, 95% CI 1.42 to 1.92, 2 RCTs, n = 3593, I2 = 0%, high-quality evidence). Menstrual delay was more common with mifepristone than with any other intervention and appeared to be dose-related. Cu-IUD may be associated with higher risks of abdominal pain than mifepristone (18 events in 95 women using Cu-IUD versus no events in 190 women using mifepristone, low-quality evidence). AUTHORS' CONCLUSIONS Levonorgestrel and mid-dose mifepristone (25 mg to 50 mg) were more effective than Yuzpe regimen. Both mid-dose (25 mg to 50 mg) and low-dose mifepristone(less than 25 mg) were probably more effective than levonorgestrel (1.5 mg). Mifepristone low dose (less than 25 mg) was less effective than mid-dose mifepristone. UPA may be more effective than levonorgestrel.Levonorgestrel users had fewer side effects than Yuzpe users, and appeared to be more likely to have a menstrual return before the expected date. UPA users were probably more likely to have a menstrual return after the expected date. Menstrual delay was probably the main adverse effect of mifepristone and seemed to be dose-related. Cu-IUD may be associated with higher risks of abdominal pain than ECPs.
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Affiliation(s)
- Jie Shen
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
| | - Yan Che
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
| | | | - Ke Chen
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
| | - Linan Cheng
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
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Shurie S, Were E, Orang'o O, Keter A. Levonorgestrel only emergency contraceptive use and risk of ectopic pregnancy in Eldoret Kenya: a case-control study. Pan Afr Med J 2018; 31:214. [PMID: 31447973 PMCID: PMC6691316 DOI: 10.11604/pamj.2018.31.214.17484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 11/08/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION ectopic pregnancy is one of the causes of maternal morbidity and mortality in sub-Saharan Africa. Levonorgestrel (LNG) only emergency contraceptive pill is a well-established emergency contraceptive pill that is administered within 72 hours after unprotected intercourse. This study aimed at determining whether or not there is a significant association between levonorgestrel emergency contraceptive use and the occurrence of ectopic pregnancy. METHODS case-control (1:3) study among 79 women with ectopic pregnancy (cases) matched against 237 women without (controls) at Moi Teaching and Referral Hospital in Eldoret, Kenya; Sociodemographic and clinical data were collected using a questionnaire. Association between ectopic pregnancy and LNG-EC was assessed using Pearson chi-square test. The relationship between outcome and exposure (while adjusting for confounders) was assessed using logistic regression model. RESULTS The mean age was 27.15 years. Both cases and controls were similar by age (p = 0.990), educational level (p = 0.850), marital status (p = 0.559), employment status (p = 0.186) and parity (p = 0.999). Seventy-eight (24.7%) participants had a history of miscarriage. A higher proportion of the cases had history of using LNG-EC compared to the controls (32.9% vs. 7.2%, p < 0.001). The use of LNG-EC portended more than nine times increased odds of ectopic pregnancy compared to other contraceptive methods {OR = 9.34 (95% CI: 3.9 - 16.0)}. CONCLUSION levonorgestrel only emergency contraceptive use was associated with ectopic pregnancy. One of the limitations of this study is that we could not control for all confounders of ectopic pregnancy.
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Affiliation(s)
- Sahara Shurie
- Department of Reproductive Health, College of Health Sciences Moi University, Eldoret, Kenya
| | - Edwin Were
- Department of Reproductive Health, College of Health Sciences Moi University, Eldoret, Kenya
| | - Omenge Orang'o
- Department of Reproductive Health, College of Health Sciences Moi University, Eldoret, Kenya
| | - Alfred Keter
- Department of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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Hamdaoui N, Cardinale C, Agostini A. [Emergency contraception: CNGOF Contraception Guidelines]. ACTA ACUST UNITED AC 2018; 46:799-805. [PMID: 30389544 DOI: 10.1016/j.gofs.2018.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Edit, by the French National College of Gynecologists and Obstetricians (CNGOF), recommendations based on the evidence available in the literature for the use in terms of effectiveness, safety and side effects of emergency contraception (EC). METHODS A review of the literature was conducted by consulting Medline, Cochrane Library and international recommendations in French and English from January 1, 1979 to May 1, 2018. RESULTS It is recommended to inform patients that EC is not 100% effective. A pregnancy test is recommended if there is a delay after taking an EC. It is recommended to use EC as soon as possible after the unprotected intercourse. In the absence of long-term contraception, in the first 72hours after unprotected intercourse, ulipristal acetate (UPA) and levonorgestrel (LNG) may be offered with a superiority of UPA from 0 to 72h. Beyond 72hours, the data suggest a better efficiency of the UPA. However, taking into account practical elements (access to EC, cost, impact on the taking of hormonal contraception after UPA), it is difficult to recommend the UPA as a priority between 0 and 72h. Menstruation is more likely to happen early with LNG. The copper IUD is an effective method that can be used in EC until 120hours after unprotected intercourse or when there is a risk of contraceptive failure. CONCLUSIONS EC is not 100% effective. The closer the intake of EC with the unprotected intercourse, the more effective is the EC in terms of pregnancy rate.
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Affiliation(s)
- N Hamdaoui
- Service de gynécologie-obstétrique, hôpital de la Conception, boulevard Baille, 13005 Marseille, France.
| | - C Cardinale
- Service de gynécologie-obstétrique, hôpital de la Conception, boulevard Baille, 13005 Marseille, France
| | - A Agostini
- Service de gynécologie-obstétrique, hôpital de la Conception, boulevard Baille, 13005 Marseille, France
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Bellows BK, Tak CR, Sanders JN, Turok DK, Schwarz EB. Cost-effectiveness of emergency contraception options over 1 year. Am J Obstet Gynecol 2018; 218:508.e1-508.e9. [PMID: 29409847 DOI: 10.1016/j.ajog.2018.01.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/28/2017] [Accepted: 01/22/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND The copper intrauterine device is the most effective form of emergency contraception and can also provide long-term contraception. The levonorgestrel intrauterine device has also been studied in combination with oral levonorgestrel for women seeking emergency contraception. However, intrauterine devices have higher up-front costs than oral methods, such as ulipristal acetate and levonorgestrel. Health care payers and decision makers (eg, health care insurers, government programs) with financial constraints must determine if the increased effectiveness of intrauterine device emergency contraception methods are worth the additional costs. OBJECTIVE We sought to compare the cost-effectiveness of 4 emergency contraception strategies-ulipristal acetate, oral levonorgestrel, copper intrauterine device, and oral levonorgestrel plus same-day levonorgestrel intrauterine device-over 1 year from a US payer perspective. STUDY DESIGN Costs (2017 US dollars) and pregnancies were estimated over 1 year using a Markov model of 1000 women seeking emergency contraception. Every 28-day cycle, the model estimated the predicted number of pregnancy outcomes (ie, live birth, ectopic pregnancy, spontaneous abortion, or induced abortion) resulting from emergency contraception failure and subsequent contraception use. Model inputs were derived from published literature and national sources. An emergency contraception strategy was considered cost-effective if the incremental cost-effectiveness ratio (ie, the cost to prevent 1 additional pregnancy) was less than the weighted average cost of pregnancy outcomes in the United States ($5167). The incremental cost-effectiveness ratios and probability of being the most cost-effective emergency contraception strategy were calculated from 1000 probabilistic model iterations. One-way sensitivity analyses were used to examine uncertainty in the cost of emergency contraception, subsequent contraception, and pregnancy outcomes as well as the model probabilities. RESULTS In 1000 women seeking emergency contraception, the model estimated direct medical costs of $1,228,000 and 137 unintended pregnancies with ulipristal acetate, compared to $1,279,000 and 150 unintended pregnancies with oral levonorgestrel, $1,376,000 and 61 unintended pregnancies with copper intrauterine devices, and $1,558,000 and 63 unintended pregnancies with oral levonorgestrel plus same-day levonorgestrel intrauterine device. The copper intrauterine device was the most cost-effective emergency contraception strategy in the majority (63.9%) of model iterations and, compared to ulipristal acetate, cost $1957 per additional pregnancy prevented. Model estimates were most sensitive to changes in the cost of the copper intrauterine device (with higher copper intrauterine device costs, oral levonorgestrel plus same-day levonorgestrel intrauterine device became the most cost-effective option) and the cost of a live birth (with lower-cost births, ulipristal acetate became the most cost-effective option). When the proportion of obese women in the population increased, the copper intrauterine device became even more most cost-effective. CONCLUSION Over 1 year, the copper intrauterine device is currently the most cost-effective emergency contraception option. Policy makers and health care insurance companies should consider the potential for long-term savings when women seeking emergency contraception can promptly obtain whatever contraceptive best meets their personal preferences and needs; this will require removing barriers and promoting access to intrauterine devices at emergency contraception visits.
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Affiliation(s)
- Brandon K Bellows
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT; SelectHealth, Murray, UT.
| | - Casey R Tak
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
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Goodman SR, El Ayadi AM, Rocca CH, Kohn JE, Benedict CE, Dieseldorff JR, Harper CC. The intrauterine device as emergency contraception: how much do young women know? Contraception 2018; 98:S0010-7824(18)30145-8. [PMID: 29679591 PMCID: PMC6546552 DOI: 10.1016/j.contraception.2018.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/10/2018] [Accepted: 04/11/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Unprotected intercourse is common, especially among teens and young women. Access to intrauterine device (IUD) as emergency contraception (EC) can help interested patients more effectively prevent unintended pregnancy and can also offer ongoing contraception. This study evaluated young women's awareness of IUD as EC and interest in case of need. STUDY DESIGN We conducted a secondary analysis of data from young women aged 18-25 years, not desiring pregnancy within 12 months, and receiving contraceptive counseling within a cluster-randomized trial in 40 US Planned Parenthood health centers in 2011-2013 (n=1500). Heath centers were randomized to receive enhanced training on contraceptive counseling and IUD placement, or to provide standard care. The intervention did not focus specifically on IUD as EC. We assessed awareness of IUD as EC, desire to learn more about EC and most trusted source of information of EC among women in both intervention and control groups completing baseline and 3- or 6-month follow-up questionnaires (n=1138). RESULTS At follow-up, very few young women overall (7.5%) visiting health centers had heard of IUD as EC. However, if they needed EC, most (68%) reported that they would want to learn about IUDs in addition to EC pills, especially those who would be very unhappy to become pregnant (adjusted odds ratio [aOR], 1.3; 95% confidence interval, 1.0-1.6, p<.05). Most (91%) reported a doctor or nurse as their most trusted source of EC information, over Internet (6%) or friends (2%), highlighting providers' essential role. CONCLUSION Most young women at risk of unintended pregnancy are not aware of IUD as EC and look to their providers for trusted information. Contraceptive education should explicitly address IUD as EC. IMPLICATIONS Few young women know that the IUD can be used for EC or about its effectiveness. However, if they needed EC, most reported that they would want to learn about IUDs in addition to EC pills, especially those very unhappy to become pregnant. Contraceptive education should explicitly address IUD as EC.
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Affiliation(s)
- Suzan R Goodman
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA.
| | - Alison M El Ayadi
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA
| | - Corinne H Rocca
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA
| | - Julia E Kohn
- Planned Parenthood Federation of America, 123 William Street, New York, NY 10038, USA
| | - Courtney E Benedict
- Planned Parenthood Federation of America, 123 William Street, New York, NY 10038, USA
| | | | - Cynthia C Harper
- UCSF Bixby Center for Global Reproductive Health, 3333 California Street, UCSF Box 0744, San Francisco, CA 94143-0744, USA
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Abstract
PURPOSE OF REVIEW Emergency contraception provides a critical and time-sensitive opportunity for women to prevent undesired pregnancy after intercourse. Both access and available options for emergency contraception have changed over the last several years. RECENT FINDINGS Emergency contraceptive pills can be less effective in obese women. The maximum achieved serum concentration of levonorgestrel (LNG) is lower in obese women than women of normal BMI, and doubling the dose of LNG (3 mg) increases its concentration maximum, approximating the level in normal BMI women receiving one dose of LNG. Repeated use of both LNG and ulipristal acetate (UPA) is well tolerated. Hormonal contraception can be immediately started following LNG use, but should be delayed for 5 days after UPA use to avoid dampening the efficacy of UPA. The copper intrauterine device (IUD) is the only IUD approved for emergency contraception (and the most effective method of emergency contraception), but use of LNG IUD as emergency contraception is currently being investigated. Accurate knowledge about emergency contraception remains low both for patients and healthcare providers. SUMMARY Emergency contraception is an important yet underutilized tool available to women to prevent pregnancy. Current options including copper IUD and emergency contraceptive pills are safe and well tolerated. Significant gaps in knowledge of emergency contraception on both the provider and user level exist, as do barriers to expedient access of emergency contraception.
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Emergency Contraception. Nurs Womens Health 2017; 21:506-508. [PMID: 29223214 DOI: 10.1016/s1751-4851(17)30328-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol 2017; 130:e251-e269. [PMID: 29064972 DOI: 10.1097/aog.0000000000002400] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective reversible contraceptive methods. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. In addition, after the device is removed, the return of fertility is rapid (1, 2). The purpose of this Practice Bulletin is to provide information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. The management of clinical challenges associated with LARC use is beyond the scope of this document and is addressed in Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods (3).
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Abstract
BACKGROUND Emergency contraception (EC) is using a drug or copper intrauterine device (Cu-IUD) to prevent pregnancy shortly after unprotected intercourse. Several interventions are available for EC. Information on the comparative effectiveness, safety and convenience of these methods is crucial for reproductive healthcare providers and the women they serve. This is an update of a review previously published in 2009 and 2012. OBJECTIVES To determine which EC method following unprotected intercourse is the most effective, safe and convenient to prevent pregnancy. SEARCH METHODS In February 2017 we searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Popline and PubMed, The Chinese biomedical databases and UNDP/UNFPA/WHO/World Bank Special Programme on Human Reproduction (HRP) emergency contraception database. We also searched ICTRP and ClinicalTrials.gov as well as contacting content experts and pharmaceutical companies, and searching reference lists of appropriate papers. SELECTION CRITERIA Randomised controlled trials including women attending services for EC following a single act of unprotected intercourse were eligible. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. The primary review outcome was observed number of pregnancies. Side effects and changes of menses were secondary outcomes. MAIN RESULTS We included 115 trials with 60,479 women in this review. The quality of the evidence for the primary outcome ranged from moderate to high, and for other outcomes ranged from very low to high. The main limitations were risk of bias (associated with poor reporting of methods), imprecision and inconsistency. Comparative effectiveness of different emergency contraceptive pills (ECP)Levonorgestrel was associated with fewer pregnancies than Yuzpe (estradiol-levonorgestrel combination) (RR 0.57, 95% CI 0.39 to 0.84, 6 RCTs, n = 4750, I2 = 23%, high-quality evidence). This suggests that if the chance of pregnancy using Yuzpe is assumed to be 29 women per 1000, the chance of pregnancy using levonorgestrel would be between 11 and 24 women per 1000.Mifepristone (all doses) was associated with fewer pregnancies than Yuzpe (RR 0.14, 95% CI 0.05 to 0.41, 3 RCTs, n = 2144, I2 = 0%, high-quality evidence). This suggests that if the chance of pregnancy following Yuzpe is assumed to be 25 women per 1000 women, the chance following mifepristone would be between 1 and 10 women per 1000.Both low-dose mifepristone (less than 25 mg) and mid-dose mifepristone (25 mg to 50 mg) were probably associated with fewer pregnancies than levonorgestrel (RR 0.72, 95% CI 0.52 to 0.99, 14 RCTs, n = 8752, I2 = 0%, high-quality evidence; RR 0.61, 95% CI 0.45 to 0.83, 27 RCTs, n = 6052, I2 = 0%, moderate-quality evidence; respectively). This suggests that if the chance of pregnancy following levonorgestrel is assumed to be 20 women per 1000, the chance of pregnancy following low-dose mifepristone would be between 10 and 20 women per 1000; and that if the chance of pregnancy following levonorgestrel is assumed to be 35 women per 1000, the chance of pregnancy following mid-dose mifepristone would be between 16 and 29 women per 1000.Ulipristal acetate (UPA) was associated with fewer pregnancies than levonorgestrel (RR 0.59; 95% CI 0.35 to 0.99, 2 RCTs, n = 3448, I2 = 0%, high-quality evidence). Comparative effectiveness of different ECP dosesIt was unclear whether there was any difference in pregnancy rate between single-dose levonorgestrel (1.5 mg) and the standard two-dose regimen (0.75 mg 12 hours apart) (RR 0.84, 95% CI 0.53 to 1.33, 3 RCTs, n = 6653, I2 = 0%, moderate-quality evidence).Mid-dose mifepristone was associated with fewer pregnancies than low-dose mifepristone (RR 0.73; 95% CI 0.55 to 0.97, 25 RCTs, n = 11,914, I2 = 0%, high-quality evidence). Comparative effectiveness of Cu-IUD versus mifepristoneThere was no conclusive evidence of a difference in the risk of pregnancy between the Cu-IUD and mifepristone (RR 0.33, 95% CI 0.04 to 2.74, 2 RCTs, n = 395, low-quality evidence). Adverse effectsNausea and vomiting were the main adverse effects associated with emergency contraception. There is probably a lower risk of nausea (RR 0.63, 95% CI 0.53 to 0.76, 3 RCTs, n = 2186 , I2 = 59%, moderate-quality evidence) or vomiting (RR 0.12, 95% CI 0.07 to 0.20, 3 RCTs, n = 2186, I2 = 0%, high-quality evidence) associated with mifepristone than with Yuzpe. levonorgestrel is probably associated with a lower risk of nausea (RR 0.40, 95% CI 0.36 to 0.44, 6 RCTs, n = 4750, I2 = 82%, moderate-quality evidence), or vomiting (RR 0.29, 95% CI 0.24 to 0.35, 5 RCTs, n = 3640, I2 = 78%, moderate-quality evidence) than Yuzpe. Levonorgestrel users were less likely to have any side effects than Yuzpe users (RR 0.80, 95% CI 0.75 to 0.86; 1 RCT, n = 1955, high-quality evidence). UPA users were more likely than levonorgestrel users to have resumption of menstruation after the expected date (RR 1.65, 95% CI 1.42 to 1.92, 2 RCTs, n = 3593, I2 = 0%, high-quality evidence). Menstrual delay was more common with mifepristone than with any other intervention and appeared to be dose-related. Cu-IUD may be associated with higher risks of abdominal pain than mifepristone (18 events in 95 women using Cu-IUD versus no events in 190 women using mifepristone, low-quality evidence). AUTHORS' CONCLUSIONS Levonorgestrel and mid-dose mifepristone (25 mg to 50 mg) were more effective than Yuzpe regimen. Both mid-dose (25 mg to 50 mg) and low-dose mifepristone(less than 25 mg) were probably more effective than levonorgestrel (1.5 mg). Mifepristone low dose (less than 25 mg) was less effective than mid-dose mifepristone. UPA was more effective than levonorgestrel.Levonorgestrel users had fewer side effects than Yuzpe users, and appeared to be more likely to have a menstrual return before the expected date. UPA users were probably more likely to have a menstrual return after the expected date. Menstrual delay was probably the main adverse effect of mifepristone and seemed to be dose-related. Cu-IUD may be associated with higher risks of abdominal pain than ECPs.
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Key Words
- female
- humans
- pregnancy
- contraception, postcoital
- contraception, postcoital/adverse effects
- contraception, postcoital/methods
- contraceptives, postcoital
- contraceptives, postcoital/administration & dosage
- contraceptives, postcoital/adverse effects
- drug administration schedule
- estradiol
- estradiol/administration & dosage
- estradiol/adverse effects
- intrauterine devices, copper
- intrauterine devices, copper/adverse effects
- intrauterine devices, medicated
- intrauterine devices, medicated/adverse effects
- levonorgestrel
- levonorgestrel/administration & dosage
- levonorgestrel/adverse effects
- mifepristone
- mifepristone/administration & dosage
- mifepristone/adverse effects
- norpregnadienes
- norpregnadienes/administration & dosage
- norpregnadienes/adverse effects
- pregnancy rate
- randomized controlled trials as topic
- unsafe sex
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Affiliation(s)
- Jie Shen
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
| | - Yan Che
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
| | | | - Ke Chen
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
| | - Linan Cheng
- Key Laboratory of Reproduction Regulation of NPFPC, SIPPR, IRD, Fudan UniversityCentre for Clinical Research and Training2140 Xie Tu RoadShanghaiChina
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Sanders JN, Turok DK, Royer PA, Thompson IS, Gawron LM, Storck KE. One-year continuation of copper or levonorgestrel intrauterine devices initiated at the time of emergency contraception. Contraception 2017; 96:99-105. [PMID: 28596121 PMCID: PMC6040824 DOI: 10.1016/j.contraception.2017.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVE(S) This study compares 1-year intrauterine device (IUD) continuation among women presenting for emergency contraception (EC) and initiating the copper (Cu T380A) IUD or the levonorgestrel (LNG) 52 mg IUD plus 1.5 mg oral LNG. STUDY DESIGN This cohort study enrolled 188 women who presented at a single family planning clinic in Utah between June 2013 and September 2014 and selected either the Cu T380A IUD or LNG 52 mg IUD plus oral LNG for EC. Trained personnel followed participants by phone, text or e-mail for 12 months or until discontinuation occurred. We assessed reasons for discontinuation and used Cox proportional hazard models, Kaplan-Meier estimates and log-rank tests to assess differences in continuation rates between IUDs. RESULTS One hundred seventy-six women received IUDs; 66 (37%) chose the Cu T380A IUD and 110 (63%) chose the LNG 52 mg IUD plus oral LNG. At 1 year, we accounted for 147 (84%) participants, 33 (22%) had requested removals, 13 (9%) had an expulsion and declined reinsertion, 3 (2%) had a pregnancy with their IUD in place and 98 (67%) were still using their device. Continuation rates did not differ by IUD type; 60% of Cu T380A IUD users and 70% of LNG 52 mg IUD plus oral LNG users were still using their device at 12 months (adjusted hazard ratio 0.72, 95% confidence interval 0.40-1.3). CONCLUSION(S) Two-thirds of women who chose IUD placement at the EC clinical encounter continued use at 1 year. Women initiating Cu T380A IUD and LNG 52 mg IUD had similar 1-year continuation rates. These findings support same-day insertion of IUDs for women who are seeking EC and would like to use a highly effective reversible method going forward. IMPLICATIONS Providing IUD options for EC users presents an opportunity to increase availability of highly effective contraception.
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Affiliation(s)
- J N Sanders
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA.
| | - D K Turok
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - P A Royer
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - I S Thompson
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - L M Gawron
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
| | - K E Storck
- Department of Obstetrics and Gynecology, University of Utah, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209, USA
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Stone R, Rafie S, El-Ibiary SY, Vernon V, Lodise NM. Emergency Contraception Algorithm and Guide for Clinicians. Nurs Womens Health 2017; 21:297-305. [PMID: 28784210 DOI: 10.1016/j.nwh.2017.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/23/2017] [Indexed: 06/07/2023]
Abstract
There are currently three forms of emergency contraception: oral levonorgestrel, oral ulipristal acetate, and the copper intrauterine device. The copper intrauterine device is the most effective, followed by ulipristal acetate and levonorgestrel, respectively. Although levonorgestrel is the least effective method, studies show that more prescribers are familiar with it and that is the most frequently used method. Clinicians should consider several factors when helping women make informed medical decisions regarding emergency contraception, including access to the products, a woman's individual preference, timing since unprotected intercourse, body mass index or weight, and initiation or resumption of routine contraception. This article explains and summarizes these considerations and provides an algorithm to guide clinicians.
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Hoopes AJ, Simmons KB, Godfrey EM, Sucato GS. 2016 Updates to US Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for Contraceptive Use: Highlights for Adolescent Patients. J Pediatr Adolesc Gynecol 2017; 30:149-155. [PMID: 28167141 DOI: 10.1016/j.jpag.2017.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
The US Medical Eligibility Criteria for Contraceptive Use (MEC) and US Selected Practice Recommendations for Contraceptive Use (SPR) provide evidence-based guidance to safely provide contraception counseling and services. Both documents were updated in 2016 and are endorsed by the North American Society for Pediatric and Adolescent Gynecology. The purpose of this mini-review is to highlight updates to the US MEC and US SPR that are most relevant to health care providers of adolescents to support dissemination and implementation of these evidence-based best practices. This document is intended to highlight these changes and to complement, not replace, the detailed practice guidance within the US MEC and US SPR.
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Affiliation(s)
| | - Katharine B Simmons
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Emily M Godfrey
- Departments of Family Medicine and Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
| | - Gina S Sucato
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Royer PA, Turok DK, Sanders JN, Saltzman HM. Choice of Emergency Contraceptive and Decision Making Regarding Subsequent Unintended Pregnancy. J Womens Health (Larchmt) 2016; 25:1038-1043. [PMID: 27032057 PMCID: PMC5069714 DOI: 10.1089/jwh.2015.5625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To prospectively evaluate (1) pregnancy desirability, (2) stated intentions should pregnancy occur among emergency contraception (EC) users, and (3) explore differences between women selecting the copper T380 intrauterine device (Cu IUD) or oral levonorgestrel (LNG) regarding hypothetical pregnancy plans and actual pregnancy actions during subsequent unintended pregnancies. STUDY DESIGN In this prospective observational trial, women received the Cu IUD or oral LNG for EC without cost barriers. At baseline, participants completed a visual analogue scale measuring pregnancy desirability (anchors: 0, "trying hard not to get pregnant"; 10, "trying hard to get pregnant") and self-reported plans (abortion, adoption, parenting, and unsure) if the pregnancy test were to come back positive. Pregnancies were tracked for 12 months, and actions regarding unintended pregnancies were compared between EC method groups. RESULTS Of 548 enrolled women, 218 chose the Cu IUD and 330 the oral LNG for EC. Pregnancy desirability at baseline was low, with no difference between EC groups (IUD group: 0.51, SD ± 1.60; LNG group: 0.68, SD ± 1.74). Fifty-four (10%) women experienced unintended pregnancies. Pregnancy plans from baseline changed for 27 (50%) women when they became pregnant. EC groups did not differ in hypothetical pregnancy intention (p = 0.15) or in agreement of hypothetical pregnancy intention with actual pregnancy action (p = 0.80). CONCLUSIONS Women presenting for EC state high desire to prevent pregnancy regardless of method selected. When considering a hypothetical pregnancy, half of women had a plan for how they would respond to that situation, but when confronting an actual unintended pregnancy, half altered their plan. CLINICAL TRIAL REGISTRATION NUMBER Clinicaltrials.gov identifier NCT00966771.
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Affiliation(s)
- Pamela A Royer
- Department of Obstetrics and Gynecology, University of Utah , Salt Lake City, Utah
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah , Salt Lake City, Utah
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah , Salt Lake City, Utah
| | - Hanna M Saltzman
- Department of Obstetrics and Gynecology, University of Utah , Salt Lake City, Utah
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21
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Simmons KB, Edelman AB. Hormonal contraception and obesity. Fertil Steril 2016; 106:1282-1288. [PMID: 27565257 DOI: 10.1016/j.fertnstert.2016.07.1094] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 12/18/2022]
Abstract
The rising rate of overweight and obesity is a public health crisis in the United States and increasingly around the globe. Rates of contraceptive use are similar among women of all weights, but because contraceptive development studies historically excluded women over 130% of ideal body weight, patients and providers have a gap in understanding of contraceptive efficacy for obese and overweight women. Because of a range of drug metabolism alterations in obesity, there is biologic plausibility for changes in hormonal contraception effectiveness in obese women. However, these pharmacokinetic changes are not linearly related to body mass index or weight, and it is unknown what degree of obesity begins to affect pharmacokinetic or pharmacodynamics processes. Overall, most studies of higher quality do not demonstrate a difference in oral contraceptive pill effectiveness in obese compared with non-obese women. However, data are scant for women in the highest categories of obesity, and differences by progestin type are incompletely understood. Effectiveness of most non-oral contraceptives does not seem to be compromised in obesity. Exceptions to this include the combined hormonal patch and oral levonorgestrel emergency contraception, which may have lower rates of effectiveness in obese women. The purpose of this review is to summarize evidence on contraceptive use in women with obesity, including differences in steroid hormone metabolism, contraceptive effectiveness, and safety, compared with women of normal weight or body mass index using the same methods.
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Affiliation(s)
- Katharine B Simmons
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon.
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EC4U: results from a pilot project integrating the copper IUC into emergency contraceptive care. Contraception 2016; 94:48-51. [DOI: 10.1016/j.contraception.2016.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 02/06/2016] [Accepted: 02/08/2016] [Indexed: 12/30/2022]
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Wright RL, Frost CJ, Turok DK. Experiences of Advanced Practitioners with Inserting the Copper Intrauterine Device as Emergency Contraception. Womens Health Issues 2016; 26:523-8. [PMID: 27264913 DOI: 10.1016/j.whi.2016.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 04/19/2016] [Accepted: 04/26/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The copper intrauterine device (IUD) is the most effective method of emergency contraception (EC) available for use after unprotected intercourse. Family planning clinics, commonly staffed by advanced practice clinicians, fulfill a significant role in health care and contraceptive service delivery for women in the United States. There are limited data assessing the perspectives and experiences of these providers in using the copper IUD as EC in these settings. METHODS Semistructured individual interviews were conducted with 12 advanced practice clinicians with experience inserting the copper IUD. A phenomenological approach was used to frame the study and analysis. A modified version of the Van Kaam method of analysis was used to analyze the data from interview transcripts. RESULTS Participants reported feelings of responsibility to support long-acting and highly effective methods of contraception. Patients' abilities to provide an accurate history of the last instance of unprotected intercourse in relation to their menstrual cycles and fear of painful insertions influenced participants' willingness to offer the copper IUD. This included provider concerns about causing uterine perforation prompting discontinuation of IUD insertion attempts. The participants perceived patients as having little knowledge about the copper IUD in general and as not being committed to using the copper IUD long term. CONCLUSIONS Numerous factors influenced advanced practice clinicians' decisions to present the copper IUD as a method of EC. Promoting support and sharing practitioner experiences with inserting the copper IUD as EC may increase practitioner comfort with the copper IUD as EC.
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Affiliation(s)
- Rachel L Wright
- Department of Social Work, Appalachian State University, Boone, North Carolina.
| | - Caren J Frost
- College of Social Work, University of Utah, Salt Lake City, Utah
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
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Envall N, Groes Kofoed N, Kopp-Kallner H. Use of effective contraception 6 months after emergency contraception with a copper intrauterine device or ulipristal acetate - a prospective observational cohort study. Acta Obstet Gynecol Scand 2016; 95:887-93. [DOI: 10.1111/aogs.12916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/19/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Niklas Envall
- Swedish Association for Sexuality Education; Stockholm Sweden
- Department of Women's and Children's Health; Division of Obstetrics and Gynecology; Karolinska Institute; Stockholm Sweden
| | - Nina Groes Kofoed
- Department of Obstetrics and Gynecology; Danderyd Hospital; Stockholm Sweden
| | - Helena Kopp-Kallner
- Department of Women's and Children's Health; Division of Obstetrics and Gynecology; Karolinska Institute; Stockholm Sweden
- Department of Obstetrics and Gynecology; Danderyd Hospital; Stockholm Sweden
- Department of Clinical Sciences at Danderyd Hospital; Division of Obstetrics and Gynecology; Karolinska Institute; Stockholm Sweden
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Turok DK, Sanders JN, Thompson IS, Royer PA, Eggebroten J, Gawron LM. Preference for and efficacy of oral levonorgestrel for emergency contraception with concomitant placement of a levonorgestrel IUD: a prospective cohort study. Contraception 2016; 93:526-32. [PMID: 26944863 DOI: 10.1016/j.contraception.2016.01.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/19/2016] [Accepted: 01/19/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES We assessed intrauterine device (IUD) preference among women presenting for emergency contraception (EC) and the probability of pregnancy among concurrent oral levonorgestrel (LNG) plus LNG 52 mg IUD EC users. METHODS We offered women presenting for EC at a single family planning clinic the CuT380A IUD (copper IUD) or oral LNG 1.5 mg plus the LNG 52 mg IUD. Two weeks after IUD insertion, participants reported the results of a self-administered home urine pregnancy test. The primary outcome, EC failure, was defined as pregnancies resulting from intercourse occurring within five days prior to IUD insertion. RESULTS One hundred eighty-eight women enrolled and provided information regarding their current menstrual cycle and recent unprotected intercourse. Sixty-seven (36%) chose the copper IUD and 121 (64%) chose oral LNG plus the LNG IUD. The probability of pregnancy two weeks after oral LNG plus LNG IUD EC use was 0.9% (95% CI 0.0-5.1%). The only positive pregnancy test after treatment occurred in a woman who received oral LNG plus the LNG IUD and who had reported multiple episodes of unprotected intercourse including an episode more than 5 days prior to treatment. CONCLUSIONS Study participants seeking EC who desired an IUD preferentially chose oral LNG 1.5 mg with the LNG 52 mg IUD over the copper IUD. Neither group had EC treatment failures. Including the option of oral LNG 1.5 mg with concomitant insertion of the LNG 52 mg IUD in EC counseling may increase the number of EC users who opt to initiate highly effective reversible contraception. IMPLICATIONS Consideration should be given to LNG IUD insertion with concomitant use of oral LNG 1.5 mg for EC. Use of this combination may increase the number of women initiating highly effective contraception at the time of their EC visit.
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Affiliation(s)
- David K Turok
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209.
| | - Jessica N Sanders
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Ivana S Thompson
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Pamela A Royer
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Jennifer Eggebroten
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
| | - Lori M Gawron
- University of Utah, Department of Obstetrics and Gynecology, 30 North 1900 East, Room 2B200, Salt Lake City, UT 84132-2209
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Abstract
Emergency contraception, also known as postcoital contraception, is therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Common indications for emergency contraception include contraceptive failure (eg, condom breakage or missed doses of oral contraceptives) and failure to use any form of contraception (). Although oral emergency contraception was first described in the medical literature in the 1960s, the U.S. Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998. Since then, several new products have been introduced. Methods of emergency contraception include oral administration of combined estrogen-progestin, progestin only, or selective progesterone receptor modulators and insertion of a copper intrauterine device (IUD). Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when a need arises (). The purpose of this Practice Bulletin is to review the evidence for the efficacy and safety of available methods of emergency contraception and to increase awareness of these methods among obstetrician-gynecologists and other gynecologic providers.
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Jamin C, Agostini A, Asselin I, Ben M'barek I, Bettahar K, Carbonne B, David P, Faucher P, Fernandez H, Fournet P, Goffinet F, Guilbaud L, Hassoun D, Lachowsky M, Letombe B, Levy G, Trignol-Viguier N, Vayssiere C, Vigoureux S. [Emergency contraceptions: Propositions of the Orthogenics Commission of the French National College of Gynecology and Obstetrics]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2015; 43:571-4. [PMID: 26298815 DOI: 10.1016/j.gyobfe.2015.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 07/07/2015] [Indexed: 12/30/2022]
Affiliation(s)
- C Jamin
- 169, boulevard Haussmann, 75008 Paris, France.
| | - A Agostini
- 169, boulevard Haussmann, 75008 Paris, France
| | - I Asselin
- 169, boulevard Haussmann, 75008 Paris, France
| | | | - K Bettahar
- 169, boulevard Haussmann, 75008 Paris, France
| | - B Carbonne
- 169, boulevard Haussmann, 75008 Paris, France
| | - P David
- 169, boulevard Haussmann, 75008 Paris, France
| | - P Faucher
- 169, boulevard Haussmann, 75008 Paris, France
| | - H Fernandez
- 169, boulevard Haussmann, 75008 Paris, France
| | - P Fournet
- 169, boulevard Haussmann, 75008 Paris, France
| | - F Goffinet
- 169, boulevard Haussmann, 75008 Paris, France
| | - L Guilbaud
- 169, boulevard Haussmann, 75008 Paris, France
| | - D Hassoun
- 169, boulevard Haussmann, 75008 Paris, France
| | - M Lachowsky
- 169, boulevard Haussmann, 75008 Paris, France
| | - B Letombe
- 169, boulevard Haussmann, 75008 Paris, France
| | - G Levy
- 169, boulevard Haussmann, 75008 Paris, France
| | | | - C Vayssiere
- 169, boulevard Haussmann, 75008 Paris, France
| | - S Vigoureux
- 169, boulevard Haussmann, 75008 Paris, France
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Long-acting reversible contraception in the pediatric emergency department: clinical implications and common challenges. Pediatr Emerg Care 2015; 31:286-92; quiz 293-5. [PMID: 25831033 DOI: 10.1097/pec.0000000000000406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents and young adults. As the use of LARC increases, pediatric emergency medicine clinicians should be able to recognize different types of LARC and address their common adverse effects, adverse reactions, and complications. This continuing medical education activity provides an overview of LARC and will assist clinicians in the evaluation and management of patients with LARC-associated complaints.
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Thompson K, Belden P. Counseling for emergency contraception: time for a tiered approach. Contraception 2014; 90:559-61. [PMID: 25444255 DOI: 10.1016/j.contraception.2014.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/05/2014] [Accepted: 09/09/2014] [Indexed: 12/30/2022]
Affiliation(s)
- Kirsten Thompson
- Bixby Center for Global Reproductive Health, University of California, San Francisco, 3333 California Street, Suite 335, Box 0744, San Francisco, CA 94143.
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Cleland K, Raymond EG, Westley E, Trussell J. Emergency contraception review: evidence-based recommendations for clinicians. Clin Obstet Gynecol 2014; 57:741-50. [PMID: 25254919 PMCID: PMC4216625 DOI: 10.1097/grf.0000000000000056] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Several options for emergency contraception are available in the United States. This article describes each method, including efficacy, mode of action, safety, side effect profile, and availability. The most effective emergency contraceptive is the copper intrauterine device (IUD), followed by ulipristal acetate and levonorgestrel pills. Levonorgestrel is available for sale without restrictions, whereas ulipristal acetate is available with prescription only, and the copper IUD must be inserted by a clinician. Although EC pills have not been shown to reduce pregnancy or abortion rates at the population level, they are an important option for individual women seeking to prevent pregnancy after sex.
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Affiliation(s)
- Kelly Cleland
- Office of Population Research, Princeton University, Princeton, NJ
| | | | | | - James Trussell
- Office of Population Research, Princeton University, Princeton, NJ
- The Hull York Medical School, University of Hull, Hull England
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Torres LN, Turok DK, Sanders JN, Jacobson JC, Dermish AI, Ward K. We should really keep in touch: predictors of the ability to maintain contact with contraception clinical trial participants over 12 months. Contraception 2014; 90:575-80. [PMID: 25242443 DOI: 10.1016/j.contraception.2014.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 07/23/2014] [Accepted: 07/27/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study assesses the ability to maintain contact with participants enrolled in an emergency contraception (EC) trial with 12 months of follow-up based on the modes of contact they provided at enrollment. STUDY DESIGN Data came from a clinical trial offering women the copper intrauterine device or oral levonorgestrel for EC. A modified Poisson regression was used to assess predictors associated with the ability to contact study participants 12 months after enrollment. RESULTS Data were available for 542 participants; 443 (82%) could be contacted at 12 months. Contact at 12 months was greatest for those whose preferred the method of contact was text messaging, e-mail or any (62/68; 91% contacted) and worst for the 18 who had a landline phone (only 7 contacted; 39%). After controlling for age, having an e-mail address, text messaging, language preference, type of EC chosen and insurance, preferred contact other than phone increased the likelihood of follow-up by 10% [risk ratio (RR) 1.1 95% confidence interval (CI) 1.0-1.2], while having a landline reduced a woman's likelihood of being contacted at 12 months by 50% compared to women with a contract cell (RR 0.5, 95% CI 0.3-1.0). CONCLUSION The few women with a landline for contact had poor follow-up at 1 year, while women who preferred e-mail or text had the highest rate of follow-up. IMPLICATIONS Understanding how best to reduce loss to follow-up is an essential component of conducting a contraceptive clinical trial. Improved participant retention maximizes internal validity and allows for important clinical outcomes, such as pregnancy, to be assessed.
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Affiliation(s)
- Leah N Torres
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA.
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Jessica N Sanders
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Janet C Jacobson
- Planned Parenthood of Orange and San Bernardino Counties, Orange, CA, USA
| | | | - Katherine Ward
- University of Utah College of Nursing, Salt Lake City, UT, USA
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