Emerging options for emergency contraception

Why are pediatricians uncomfortable with prescribing emergency contraception for adolescents?

OBJECTIVE

Emergency contraception (EC) is an effective and safe method for preventing unplanned pregnancy after unprotected sexual intercourse among adolescents but is infrequently prescribed by pediatricians. Because of the scarcity of data on the discomfort with EC prescription among physicians in Brazil, this study aimed to identify associated factors with discomfort with EC prescription among pediatricians in the state of Amazonas.

METHODS

A web-based, cross-sectional study including sociodemographic data, knowledge, attitudes, and discomfort with EC prescription was used. Multivariate logistic regression and artificial intelligence methods such as decision tree and random forest analysis were used to identify factors associated with discomfort with EC prescriptions.

RESULTS

Among 151 physicians who responded to the survey, 53.0% were uncomfortable with prescribing EC, whereas only 33.1% had already prescribed it. Inexperience was significantly associated with discomfort with EC prescription (odds ratio 4.47, 95% confidence interval 1.71-11.66). Previous EC prescription was protective against discomfort with EC prescription in the three models.

CONCLUSIONS

EC is still infrequently prescribed by pediatricians because of inexperience and misconceptions. Training these professionals needs to be implemented as part of public health policies to reduce unplanned adolescent pregnancy.

Emergency Contraception: Access and Challenges at Times of Uncertainty

BACKGROUND

The UN Commission on Life-Saving Commodities for Women's and Children's Health identified emergency contraceptive pills as 1 of the 13 essential underused, low-cost, and high-impact commodities that could save the lives of millions of women and children worldwide. In the US, 2 emergency contraceptive regimens are currently approved, and their most plausible mechanism of action involves delaying and/or inhibiting ovulation.

AREAS OF UNCERTAINTY

Abortion and contraception are recognized as essential components of reproductive health care. In the US, in the wake of the Dobbs v. Jackson Women's Health Organization Supreme Court decision on June 24, 2022, 26 states began to or are expected to severely restrict abortion. It is anticipated that these restrictions will increase the demand for emergency contraception (EC). Several obstacles to EC access have been described, and these include cost, hurdles to over-the-counter purchase, low awareness, myths about their mechanisms of action, widespread misinformation, and barriers that special populations face in accessing them. The politicization of EC is a major factor limiting access. Improving sex education and health literacy, along with eHealth literacy, are important initiatives to improve EC uptake and access.

DATA SOURCES

PubMed, The Guttmacher Institute, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization, The United Nations.

THERAPEUTIC ADVANCES

A randomized noninferiority trial showed that the 52 mg levonorgestrel intrauterine device was noninferior to the copper intrauterine device when used as an EC method in the first 5 days after unprotected intercourse. This is a promising and highly effective emergency contraceptive option, particularly for overweight and obese patients, and a contraceptive option with a different bleeding profile than the copper intrauterine device.

CONCLUSIONS

EC represents an important facet of medicine and public health. The 2 medical regimens currently approved in the US are very effective, have virtually no medical contraindications, and novel formulations are actively being investigated to make them more convenient and effective for all patient populations. Barriers to accessing EC, including the widespread presence of contraception deserts, threaten to broaden and accentuate the already existing inequities and disparities in society, at a time when they have reached the dimensions of a public health crisis.

Contraceptive Behaviors in Polish Women Aged 18-35-a Cross-Sectional Study

The aim was to evaluate contraceptive behaviors, and factors affecting them, in the population of Polish-speaking women. A cross-sectional study was performed on 6763 women, current contraceptive users, aged 18 to 35. An anonymous and voluntary questionnaire written in Polish, containing 33 questions, was distributed online from January to February 2017. The Internet and doctors were the most popular sources of information about contraception (82% and 73%, respectively). Upon choosing contraception, women paid the most attention to its efficacy (85%) and its impact on health (59%). The most common methods were combined oral contraceptives (38%) and condoms (24%). In total, 51% had chosen hormonal contraception, of which 68% experienced side effects. The most frequent were decreased libido (39%) and weight gain (22%). Factors associated with the usage of hormonal or non-hormonal contraception were: education, relationship status, parenthood, number of sexual partners, frequency of intercourses, sources of information about contraception, and factors considered most important when choosing a contraceptive method. The choice between short-acting and long-acting reversible contraception was influenced by age, relationship status, parenthood, smoking, sources of information about contraception, and factors considered most important when choosing a contraceptive method. Wide access to contraception, high-quality education, and counselling should become priorities in family planning healthcare.

The context of emergency contraception use among young unmarried women in Accra, Ghana: a qualitative study

BACKGROUND

Over the past decade, awareness and use of emergency contraceptive pills (ECPs) among young women has rapidly increased in Ghana; however, the rate of unintended pregnancy among this group remains high. We conducted a qualitative study to better understand the context and patterns of ECP use among young unmarried women in Ghana.

METHODS

We conducted in-depth interviews with unmarried sexually active women aged 18-24 in Accra, Ghana to explore their perceptions, experiences, and opinions regarding sexual relationships and contraceptive methods, and to examine the factors that influence choice of ECPs. A total of 32 young women participated in the study.

RESULTS

Most participants had used ECPs at least once. Participants described being unable to plan for sexual encounters, and as a result preferred ECPs as a convenient post-coital method. Despite being widely and repeatedly used, women feared the disruptive effects of ECPs on the menstrual cycle and were concerned about long-term side-effects. ECPs were sometimes used as a back-up in cases of perceived failure of traditional methods like withdrawal. Misinformation about which drugs were ECPs, correct dosage, and safe usage were prevalent, and sometimes spread by pharmacists. Myths about pregnancy prevention techniques such as urinating or washing after sex were commonly believed, even among women who regularly used ECPs, and coincided with a misunderstanding about how hormonal contraception works.

CONCLUSIONS

ECPs appear to be a popular contraceptive choice among young urban women in Ghana, yet misinformation about their correct usage and safety is widespread. While more research on ECP use among young people is needed, these initial results point to the need to incorporate information about ECPs into adolescent comprehensive sexuality education and youth-friendly services and programmes.

Levonorgestrel only emergency contraceptive use and risk of ectopic pregnancy in Eldoret Kenya: a case-control study

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.

Repeated use of mifepristone and levonorgestrel and their effect on the ovarian function in mice

AIM

To investigate the effects of repeated mifepristone and levonorgestrel use on estrous cycle and expression of ovarian follicle-stimulating hormone receptor (FSHR) and luteinizing hormone receptor (LHR) in mice.

METHODS

Ovarian FSHR and LHR mRNA expression was measured using real-time quantitative reverse transcription-polymerase chain reaction, while the protein levels were measured using immunohistochemistry.

RESULTS

Repeated use of mifepristone and levonorgestrel significantly lengthened the estrous cycle and decreased FSHR and LHR mRNA and protein expression in the ovaries of mice at 4, 24, and 48 days after discontinuing drug use. Repeated use of mifepristone and levonorgestrel had significant main effects on estrous cycle length and the mRNA expression and protein level of ovarian FSHR and LHR. Repeated mifepristone and levonorgestrel use and withdrawal time had a significant interaction with mouse estrous cycle (F = 16.65, P < 0.05), ovarian LHR and FSHR mRNA expression (F = 563.072, P < 0.05), and protein level (F = 6.536, P < 0.05).

CONCLUSION

Repeated use of mifepristone and levonorgestrel can lead to sustained damage to ovarian function through inhibition of ovarian FSHR and LHR expression in mice.

Translational In Vivo Models for Women's Health: The Nonhuman Primate Endometrium--A Predictive Model for Assessing Steroid Receptor Modulators

Macaques and baboons display physiological responses to steroid hormones that are similar to those of women. Herein, we describe various uses of nonhuman primates for preclinical studies on menstruation, endometriosis, and as a model system to evaluate reproductive therapies and contraceptives. Our goal is to outline the strengths of the nonhuman primate model for studies leading to improved therapies for women.

Feasibility and effectiveness of unintended pregnancy prevention with low-dose mifepristone combined with misoprostol before expected menstruation

STUDY QUESTION

What is the efficacy of maintaining or restoring non-pregnant status with low-dose mifepristone combined with misoprostol administered before expected menstruation?

SUMMARY ANSWER

Low-dose mifepristone and misoprostol administered at the time of expected menstruation was effective and safe in maintaining or restoring non-pregnant status, with no obvious menstrual disturbance.

WHAT IS KNOWN ALREADY

Menstrual regulation involves the medical or mechanical stimulation of uterine sloughing in women with up to 2-3 weeks of menstrual delay. Low-dose mifepristone plus misoprostol is efficacious for termination of ultra-early pregnancy (≤ 35 days of amenorrhoea) with no obvious menstrual disturbance.

STUDY DESIGN, SIZE, DURATION

A total of 678 women fulfilled all criteria and were recruited. Seventeen women dropped out after deciding to remain pregnant and 11 others were lost to follow-up. Thus, data from 650 women who completed the procedure were included in analyses. Participants were enrolled at any time during their menstrual cycle and administered medication 1 day before expected menstruation. The end of the study was defined on a per-patient basis as the date of completion of the post-treatment menstrual cycle. The primary outcome was the efficacy of abortion induction (for pregnant women) or menstrual regulation (for non-pregnant women).

PARTICIPANTS, SETTING, METHODS

Women with regular menstrual cycles (25-35 days) were voluntarily recruited for this study between February 2012 and December 2014. Serum β-hCG was measured before mifepristone intake. Mifepristone (50 mg) was administered orally 1 day before expected menstruation and 200 µg misoprostol was administered orally on the day of expected menstruation. Efficacy, disturbance in bleeding patterns in the treatment and post-treatment cycles, satisfaction with the treatment, and subsequent contraception preference were analysed.

MAIN RESULTS AND THE ROLE OF CHANCE

Retrospective analysis of serum β-hCG levels at admission indicated that 23.3% (158/678) of the women were pregnant. The success rate for pregnancy termination was 98.6% (136/138). Two women (1.5%, 2/138) had ongoing pregnancy that was subsequently terminated surgically. The overall bleeding induction rate within 7 days was 98.3% (639/650), with 100% (138/138) in pregnant participants and 97.9% (501/512) in non-pregnant participants. Most pregnant and non-pregnant participants experienced no significant menstrual disturbance during the treatment [96.3% (131/136) versus 97.6% (489/501)] or post-treatment [97.8% (133/136) versus 98.4% (493/501)] menstrual cycle. The general rate of satisfaction with the treatment was 96.7% (618/639). Generally, 36.0% (230/639) of participants preferred to use the regimen as a routine contraception method versus the 64.0% (409/639) who preferred to use it as a remedy for pregnancy prevention after unprotected sex (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Study participants were recruited from a single region; further studies should include participants from multiple centres in different cities and nations. Given the uncertain efficacy of regimen reuse, the assessment of efficacy was based solely on the first treatment administration. Studies with larger samples and long-term follow-up may provide more data on whether repeated use of this regimen hampers its efficacy.

WIDER IMPLICATIONS OF THE FINDINGS

Menstrual regulation with low-dose mifepristone and misoprostol at expected menstruation can be efficacious and highly acceptable to maintain or restore non-pregnant status, which may have potential for routine contraception.

Should the annual pelvic examination go the way of annual cervical cytology?

The value of pelvic examination for healthy asymptomatic women has been called into question given the lack of benefit for ovarian and endometrial cancer screening, the ability to screen for sexually transmitted infections without a pelvic examination, and the uncoupling of the procurement of contraception with a pelvic examination. Still, there are indications for performing pelvic examinations in symptomatic women and in some high risk women. How do we as clinicians apply current evidence and expert opinion to our medical practice? Our recommendation to consider a pelvic examination at 3-5-year intervals with cervical cancer screening to elicit gynecologic and sexual health concerns offers a compromise between continuation of unnecessary annual pelvic examinations and complete elimination of these examinations.

Benchmark pregnancy rates and the assessment of post-coital contraceptives: an update

OBJECTIVE

In 2001, we provided benchmark estimates of probability of pregnancy given a single act of intercourse. Those calculations assumed that intercourse and ovulation are independent. Subsequent research has shown that this assumption is not valid. We provide here an update of previous benchmark estimates.

STUDY DESIGN

We reanalyze earlier data from two North Carolina studies that collected daily urine samples and recorded daily intercourse for multiple menstrual cycles. One study comprised 68 sexually active women with either an intrauterine device or tubal ligation. The second was of 221 women who planned to become pregnant and had discontinued use of any birth control at enrollment. Participants had no known fertility problems. New statistical analyses were based on Monte Carlo simulations and Bayesian methods.

RESULTS

The probability that a single act of intercourse occurs within a woman's fertile window is 25%, compared with 20% in previous calculations. The probability of pregnancy with intercourse on a given menstrual cycle day is correspondingly higher than previously estimated, with the largest increases occurring on menstrual days 12-22. These increases are, however, fairly small (for example, the peak chance of conception on menstrual day 13 increased from 8.6% to 9.7%).

CONCLUSIONS

Previous benchmark rates of pregnancy with one act of intercourse were moderately underestimated due to a mistaken assumption about the independence of intercourse and ovulation.

IMPLICATIONS STATEMENT

The chance of pregnancy with a single act of unprotected intercourse is greater than previously estimated. Previous benchmarks may underestimate the efficacy of post-coital contraception.

Selective progesterone receptor modulators: an update

INTRODUCTION

Several selective progesterone receptor modulators (SPRMs) show promise in several areas of medicine and this work has been summarized by us in 2008.

AREAS COVERED

Since the publication of our reviews, several developments have taken place in the field of reproductive medicine. The first is emergency contraception (EC). Two SPRMs are clinically utilized today: mifepristone (MFP) and ulipristal acetate (UPA). MFP is available for EC in up to 120 h following unprotected intercourse. A dose of 10 mg is significantly more effective than levonorgestrel (LNG). In a metanalysis of the use of UPA versus LNG up to 72 h after unprotected intercourse, failure rates of 1.4 versus 2.2% were reported. The second is contraception. A daily dose of 2 mg MFP can block ovulation and several MFP regimens are being tested, including a vaginal ring releasing MFP. The third is the preoperative administration in women harboring leiomyomas, where clinical testing of several SPRM has shown that they can decrease uterine leiomyomas' size and substantially reduce uterine bleeding. SPRM can induce unusual, specific endometrial appearances. Many believe that these changes should not cause concern, but the issue remains controversial.

EXPERT OPINION

SPRMs are very effective in EC and for the preoperative treatment of uterine leiomyomas.