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Shay RL, Benson LS, Lokken EM, Micks EA. Same-day mifepristone prior to second-trimester induction termination with misoprostol: A retrospective cohort study. Contraception 2021; 107:29-35. [PMID: 34529952 DOI: 10.1016/j.contraception.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate whether same-day administration of mifepristone and misoprostol, compared with misoprostol alone, reduces the duration of second-trimester induction of labor for termination of pregnancy or increases the rate of fetal expulsion within 24 hours. STUDY DESIGN We conducted a retrospective analysis of patients undergoing induction of labor for pregnancy termination in the second trimester between 2009 and 2018. We compared patients who received mifepristone on the same day as the first dose of misoprostol to those who received misoprostol alone. The primary outcome was expulsion within 24 hours after the first dose of misoprostol. RESULTS Two hundred ninety-eight patients met criteria for inclusion, of whom 94 (31.5%) received same-day mifepristone. Expulsion within 24 hours occurred in 93.6% of the mifepristone-plus-misoprostol group and 79.9% of the misoprostol-only group (RR 1.17, 95%CI 1.07-1.28). Expulsion within 12 hours occurred in 56.4% of the mifepristone-plus-misoprostol group and 34.0% of the misoprostol-only group (RR 1.66, 95%CI 1.28-2.16). After adjusting for demographic and clinical characteristics, the rate of expulsion within 24 hours was similar between groups (RR 1.07, 95%CI 0.92-1.26), while the rate of expulsion within 12 hours remained different (RR 1.69, 95%CI 1.01-2.83). Median time to expulsion was shorter in the mifepristone-plus-misoprostol group than the misoprostol-only group (689 minutes vs 901 minutes, p < 0.001). CONCLUSION(S) Patients who received mifepristone on the same day as misoprostol had a shorter duration of induction termination and higher rate of success within 12 hours.
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Affiliation(s)
- Rosemary L Shay
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States.
| | - Lyndsey S Benson
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States
| | - Erica M Lokken
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States
| | - Elizabeth A Micks
- University of Washington Medical Center, Department of Obstetrics & Gynecology, Seattle, WA 98195, United States
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Kaller S, Morris N, Biggs MA, Baba CF, Rafie S, Raine-Bennett TR, Creinin MD, Berry E, Micks EA, Meckstroth KR, Averbach S, Grossman D. Pharmacists' knowledge, perspectives, and experiences with mifepristone dispensing for medication abortion. J Am Pharm Assoc (2003) 2021; 61:785-794.e1. [PMID: 34281806 DOI: 10.1016/j.japh.2021.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion. OBJECTIVE To assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician. METHODS Before providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge-using a 15-item score-and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study's final month that also assessed the pharmacists' satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists' knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual. RESULTS Among the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study's end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P < 0.001). CONCLUSION Most pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA's restriction on pharmacist dispensing of mifepristone.
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Kramer KJ, Runyan A, Micks EA, Tamakuwala S, Reid M, Syed S, Chao CR, Recanati MA. Unequal medicine harms: reflections on the experiences of an intersex physician. Sex Reprod Health Matters 2021; 29:1881211. [PMID: 33587027 PMCID: PMC7944997 DOI: 10.1080/26410397.2021.1881211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Katherine J Kramer
- Attending Physician, Department of Obstetrics and Gynecology, St. Vincent's Catholic Medical Centers, New York, NY, USA
| | - Aliye Runyan
- Attending Physician, Department of Obstetrics and Gynecology, Westchester Medical Center, Valhalla, NY, USA
| | - Elizabeth A Micks
- Assistant Professor, Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, USA
| | - Sejal Tamakuwala
- Assistant Professor, Department of Gynevology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Mary Reid
- OBGYN Resident, Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
| | - Suha Syed
- Medical Student, Wayne State University School of Medicine, Detroit, MI, USA
| | - Conrad R Chao
- Professor and Chief of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Maurice-Andre Recanati
- Assistant Professor, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Benson LS, Stevens J, Micks EA, Prager SW. Leukocytosis during cervical preparation with osmotic dilators for dilation and evacuation. SAGE Open Med 2021; 9:2050312120986731. [PMID: 33489232 PMCID: PMC7809630 DOI: 10.1177/2050312120986731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives: To describe leukocytosis trends during cervical preparation with osmotic dilators for second-trimester dilation and evacuation procedures, and to determine whether there is a difference in leukocytosis seen with laminaria versus Dilapan-S. Methods: We conducted a retrospective cohort study of 986 women presenting for dilation and evacuation from April 2008 through March 2009 at an outpatient clinic network. We included all procedures at ⩾14 weeks’ gestation where laminaria or Dilapan-S dilators were used for overnight dilation. All women had routine white blood cell testing during the study period. Results: There was a median increase of 2.4 × 103/μL white blood cell count (95% confidence interval 2.2–2.7 × 103/μL) from beginning of cervical preparation to the day of procedure (95% confidence interval and p value). Women receiving laminaria (n = 805) versus Dilapan-S (n = 181) had a greater increase in white blood cell count from baseline (median increase 2.7 versus 1.2 × 103/μL, p < 0.001), including when adjusting for age, gestational age, parity, baseline white blood cell count, and number of dilators placed. Conclusion: There is increased leukocytosis during the course of cervical preparation with osmotic dilators, and this is increased with use of laminaria versus Dilapan-S. Rates of clinically recognized infection in second-trimester abortion are low regardless of dilator type used.
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Affiliation(s)
- Lyndsey S Benson
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Jordan Stevens
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Sarah W Prager
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
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Taub RL, Ellis SA, Neal-Perry G, Magaret AS, Prager SW, Micks EA. The effect of testosterone on ovulatory function in transmasculine individuals. Am J Obstet Gynecol 2020; 223:229.e1-229.e8. [PMID: 32044312 DOI: 10.1016/j.ajog.2020.01.059] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND An estimated 1.4 million persons in the United States identify as transgender or nonbinary, signifying that their gender identity does not correspond with their assigned sex at birth. Individuals assigned female at birth may seek gender-affirming hormone therapy with testosterone. No studies have directly examined ovulatory function in transmasculine individuals using injectable testosterone. OBJECTIVES Our primary objective was to determine the effect of testosterone on ovulatory suppression in transmasculine individuals. Secondary objectives were to determine predictors of ovulation in transmasculine individuals on testosterone, and to assess the effect of testosterone on antimüllerian hormone. MATERIALS AND METHODS This prospective observational study recruited participants from a community clinic that provides gender-affirming hormone therapy. Enrolled individuals were assigned female at birth and were currently using or seeking to initiate masculinizing therapy with injectable testosterone esters (transmasculine individuals). Over a 12-week study period, participants collected daily urine samples for pregnanediol-3-glucoronide testing and completed daily electronic bleeding diaries. We assessed monthly serum mid-dosing interval testosterone, estradiol and sex hormone binding globulin, and antimüllerian hormone values at baseline and study end. Ovulation was defined as pregnanediol-3-glucoronide greater than 5 μg/mL for 3 consecutive days. The primary outcome was the proportion of participants who ovulated during the study period. We examined predictors of ovulation such as age, length of time on testosterone, serum testosterone levels, body mass index, and bleeding pattern. RESULTS From July to November 2018, we enrolled 32 individuals; 20 completed the study (14 continuing testosterone users, 6 new users). Median age was 23 years (range 18-37 years). Bleeding or spotting during the study period was noted by 41% of participants (13/32). Among continuing users, median testosterone therapy duration was 11 months (range 1-60 months). A single ovulation was observed out of a total of 61 combined months of testosterone use; however, several transient rises in pregnanediol-3-glucoronide followed by bleeding episodes were suggestive of 7 dysfunctional ovulatory cycles among 7 individuals. There was no difference in antimüllerian hormone from baseline to 12 weeks between participants initiating testosterone and continuing users of testosterone. We did not have the power to examine our intended predictors given the low numbers of ovulatory events, but found that longer time on testosterone and presence of vaginal bleeding over 12 weeks were associated with transient rises in pregnanediol-3-glucoronide. CONCLUSION This study suggests that testosterone rapidly induces hypothalamic-pituitary-gonadal suppression, resulting in anovulation in a proportion of new users. Importantly, these data also suggest that some long-term testosterone users break through the hormonal suppression and experience an ovulatory event, thereby raising concerns pertaining to the need for contraception in transmasculine individuals engaged in sexual intercourse with sperm-producing partners. Given the small number of overall participants, this work is hypothesis generating. Larger studies are needed to confirm and to clarify these findings.
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Affiliation(s)
- Rebecca L Taub
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
| | | | | | - Amalia S Magaret
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Sarah W Prager
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
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Micks EA, Jensen JT. A technology evaluation of Annovera: a segesterone acetate and ethinyl estradiol vaginal ring used to prevent pregnancy for up to one year. Expert Opin Drug Deliv 2020; 17:743-752. [PMID: 32410464 DOI: 10.1080/17425247.2020.1764529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The segesterone acetate and ethinyl estradiol contraceptive vaginal ring (SA/EE CVR) was FDA-approved in August 2018 and is now available in the U.S. The CVR is placed vaginally for 21 days followed by a 7-day ring-free interval, when withdrawal bleeding typically occurs. One ring can be used for up to a year (13 cycles). AREAS COVERED This review summarizes this novel method of contraception, including the delivery system and the hormonal components. We describe the potential market, how it is used, the pharmacokinetic properties of the device, and results of clinical trials including efficacy, bleeding profile, acceptability, and safety. EXPERT OPINION The SA/EE CVR represents the first long-lasting user-controlled hormonal contraceptive device. The bleeding pattern is highly favorable and consistent over the entire year and is associated with very low discontinuation. Efficacy and safety are similar to other methods of combined hormonal contraceptives. Unscheduled ring removals increase the risk of failure. Further studies are needed to evaluate continuous use of the ring for greater than 21 days, and potential non-contraceptive benefits of the ring such as reduced menstrual bleeding.
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Affiliation(s)
- Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington , Seattle, WA, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University , Portland, OR, USA
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Benson LS, Gilmore KC, Micks EA, McCoy E, Prager SW. Perceptions of Anal Intercourse Among Heterosexual Women: A Pilot Qualitative Study. Sex Med 2019; 7:198-206. [PMID: 30833227 PMCID: PMC6522939 DOI: 10.1016/j.esxm.2018.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/06/2018] [Accepted: 12/16/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction More than one-third of women in the U.S. have engaged in heterosexual anal intercourse (HAI), but little is known regarding women’s perceptions of HAI and motivations for engaging in this sexual behavior. Aim This study aimed to explore U.S. women’s motivations for engaging in HAI and to investigate how they navigate HAI in the context of sexual relationships. Methods Semi-structured interviews were conducted with 20 women, ages 18–50 years old, who had engaged in anal intercourse with a male partner within the past 3 months. The interview guide was developed utilizing a conceptual framework based on the Theory of Planned Behavior. Main Outcome Measure Thematic content analysis was performed, and salient themes were identified. Results Salient themes were identified in all key components of the construct, including attitudes toward the behavior, subjective norms, and perceived behavioral control. Women’s intent to engage in HAI was influenced by their attitudes toward HAI and level of control and trust with their partners. Primary motivators were partner and personal pleasure and sexual curiosity and experimentation. Conclusion The Theory of Planned Behavior construct was well suited to explore factors influencing women’s intent to engage in HAI. Most women perceive negative societal norms toward HAI. Although this does not appear to affect intention to engage in HAI, it does affect disclosure of this sexual activity with friends and healthcare providers. It is important for healthcare providers to provide open, non-judgmental counseling regarding HAI to decrease stigma, enhance communication, and improve sexual health. Benson LS, Gilmore KC, Micks EA, et al. Perceptions of Anal Intercourse Among Heterosexual Women: A Pilot Qualitative Study. Sex Med 2019;7:198–206.
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Affiliation(s)
- Lyndsey S Benson
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA.
| | - Kelly C Gilmore
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Erin McCoy
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Sarah W Prager
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
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Micks EA, Son H, Magaret A, Selke S, Johnston C, Wald A. The effect of hormonal contraception on genital herpes simplex virus-2 shedding and lesions. Contraception 2017. [DOI: 10.1016/j.contraception.2017.07.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Permanent methods of contraception are used by an estimated 220 million couples worldwide, and are often selected due to convenience, ease of use and lack of side effects. A variety of tubal occlusion techniques are available for female permanent contraception, and procedures can be performed using a transcervical or transabdominal approach. This article reviews currently available techniques for female permanent contraception and discusses considerations when helping patients choose a contraceptive method and tubal occlusion technique.
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Affiliation(s)
- Elizabeth A Micks
- Department of Obstetrics & Gynecology, University of Washington, 1959 NE Pacific St, Box 356460, Seattle, WA 98195-6460, USA
| | - Jeffrey T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
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Benson LS, Micks EA. Why Stop Now? Extended and Continuous Regimens of Combined Hormonal Contraceptive Methods. Obstet Gynecol Clin North Am 2015; 42:669-81. [DOI: 10.1016/j.ogc.2015.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Amies Oelschlager AME, Micks EA, Debiec KE, Nizamic T, Mantrala MD, Prager SW. Long acting reversible contraception in adolescents with cardiovascular conditions. J Pediatr Adolesc Gynecol 2014; 27:353-5. [PMID: 25256877 DOI: 10.1016/j.jpag.2014.01.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 01/16/2014] [Accepted: 01/18/2014] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE The purpose of this case series was to evaluate the efficacy and complication rate with use of long-acting reversible contraceptive (LARC) methods in adolescents with cardiovascular conditions. DESIGN AND PARTICIPANTS We performed a retrospective chart review of adolescents age 22 or younger with congenital cardiac anomalies or major cardiovascular conditions who had a LARC device placed at Seattle Children's Hospital or University of Washington Medical Center between January 1, 2007 and March 1, 2012. MAIN OUTCOME MEASURES Patient characteristics, medical conditions, indications, and complications including perforation, pregnancy, expulsion, and pelvic infection were collected and analyzed. RESULTS Thirty adolescents with congenital cardiac anomalies or other cardiovascular conditions had a LARC device inserted during the study period. Mean age at placement was 17.7 years (range 12-22). Twelve patients (40%) had reported a previous pregnancy and 12 (40%) had never been sexually active at time of placement. Common primary and secondary indications were desired contraception (22 patients, 73%), desired menstrual suppression (15 subjects, 50%) and treatment of heavy menstrual bleeding (8 subjects, 27%). Twenty-nine patients had a structural cardiac anomaly. There were 27 levonorgestrel-releasing intrauterine devices (IUD), 1 copper IUD, and 3 etonogestrel implants placed. There were 2 confirmed IUD expulsions and 1 removal due to persistent irregular bleeding and cramping. There were no cases of pelvic inflammatory disease or pregnancies with LARC methods in place. Twenty-seven (90%) patients were continuing LARC at last follow-up. CONCLUSIONS In this small case series of adolescents with cardiovascular conditions, LARC devices were effective at pregnancy prevention without serious complications.
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Affiliation(s)
| | - Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA
| | - Katherine E Debiec
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA
| | - Tiana Nizamic
- University of Washington School of Medicine, Seattle, WA
| | | | - Sarah W Prager
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA
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Goldthwaite LM, Baldwin MK, Page J, Micks EA, Nichols MD, Edelman AB, Bednarek PH. Comparison of interventions for pain control with tenaculum placement: a randomized clinical trial. Contraception 2014; 89:229-33. [DOI: 10.1016/j.contraception.2013.11.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 11/16/2013] [Accepted: 11/24/2013] [Indexed: 11/16/2022]
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Bednarek PH, Micks EA, Edelman AB, Li H, Jensen JT. The effect of nitroprusside on IUD insertion experience in nulliparous women: a pilot study. Contraception 2013; 87:421-5. [DOI: 10.1016/j.contraception.2012.10.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/25/2012] [Accepted: 10/26/2012] [Indexed: 11/17/2022]
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Micks EA, Edelman AB, Renner RM, Fu R, Lambert WE, Bednarek PH, Nichols MD, Beckley EH, Jensen JT. Hydrocodone–Acetaminophen for Pain Control in First-Trimester Surgical Abortion. Obstet Gynecol 2012. [DOI: http:/10.1097/aog.0b013e31826c32f0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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