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Raymond EG, Frye LJ, Tocce K, Gingras S, Almquist A, Firstenberg A, Ortega C, Blumenthal PD, Winikoff B, Boraas C. Evaluation of a "smart" screening tool for asynchronous assessment of medication abortion eligibility: A pilot study. Contraception 2024; 131:110340. [PMID: 37992850 DOI: 10.1016/j.contraception.2023.110340] [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: 08/23/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES This study aimed to assess the feasibility, safety, and acceptability of asynchronous screening for medication abortion eligibility using a programmed questionnaire. STUDY DESIGN For this study, we developed an informational website about medication abortion with a linked questionnaire programmed to produce a conclusion regarding eligibility according to standard criteria. We enrolled people in Colorado and Minnesota who submitted questionnaires indicating eligibility. A study physician reviewed each questionnaire and medical records if available and determined whether the responses warranted treatment without a synchronous clinical consultation or ultrasound. If so, the physician prescribed a standard regimen of mifepristone and misoprostol. We collected posttreatment data on abortion outcome, adverse events, and satisfaction. RESULTS We received questionnaires from 197 individuals, of whom 160 remained in the study until the physician made a final treatment decision. Physicians prescribed medication abortion to 156 (97.5%) individuals based on the questionnaire responses, whereas four needed further assessment to confirm eligibility. Of the 156 individuals, 130 had sufficient follow-up to assess abortion outcome, and 123 (95%) had complete medication abortions without additional treatment. One participant was hospitalized for bleeding, and one expelled a 15-week fetus; however, it is not clear that conventional synchronous history-based screening would have averted these events. Of the 197 questionnaires, 42% were submitted outside business hours. On satisfaction questionnaires, 134 (96%) of 144 participants said they would recommend the study to a friend who needed an abortion. CONCLUSIONS Data from this pilot project suggest that providing medication abortion based only on a self-administered, programmed questionnaire is likely to be effective, safe, efficient, and acceptable. IMPLICATIONS A programmed self-administered patient questionnaire to assess eligibility for medication abortion could reduce the cost of the service, augment clinic efficiency, improve quality of care, and enhance access to abortion.
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Affiliation(s)
| | - Laura J Frye
- Gynuity Health Projects, New York, NY, United States
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, CO, United States
| | - Shay Gingras
- Planned Parenthood North Central States, Saint Paul, MN, United States
| | - Amy Almquist
- Planned Parenthood North Central States, Saint Paul, MN, United States
| | - Ann Firstenberg
- Planned Parenthood of the Rocky Mountains, Denver, CO, United States
| | - Cynthia Ortega
- Planned Parenthood of the Rocky Mountains, Denver, CO, United States
| | - Paul D Blumenthal
- Department of Obstetrics and Gynecology, Stanford University, Palo Alto, CA, United States
| | | | - Christy Boraas
- Planned Parenthood North Central States, Saint Paul, MN, United States
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Raymond EG, Weaver MA, Shochet T. Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis. Contraception 2023; 127:110132. [PMID: 37517447 DOI: 10.1016/j.contraception.2023.110132] [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: 03/22/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES This study aimed to update our 2019 systematic review of data on the effectiveness and safety of misoprostol-only for first-trimester abortion. STUDY DESIGN We searched PubMed on December 18, 2022, to find published articles describing the outcomes of treatment with misoprostol-only for abortion of viable intrauterine pregnancy at ≤91 days of gestation. From each article identified, two authors independently abstracted relevant data about each group of patients treated with a distinct regimen. We assessed the risk of bias using four defined indicators. We estimated the proportion of patients with treatment failure using meta-analytic methods as well as the proportion hospitalized or transfused after treatment. We examined associations between treatment failure and selected characteristics of the groups. RESULTS We identified 49 papers with 66 groups that collectively included 16,354 evaluable patients, of whom 2960 (meta-analytic estimate 15%, 95% CI 12%, 19%) had treatment failures. Of 9228 patients assessed for ongoing pregnancy after treatment, 521 (meta-analytic estimate 6%, 95% CI 5%, 8%) had that condition. Failure risk was significantly associated with misoprostol dose, the total allowed number of doses, the maximum duration of dosing, and certain indicators of risk of bias. Among 11,007 patients allowed to take at least three misoprostol doses, the first consisting of misoprostol 800 mcg administered vaginally, sublingually, or buccally, the meta-analytic estimate of the failure risk was 11% (95% CI 8%, 14%). At most, 0.2% of 15,679 evaluable patients were hospitalized or received transfusions. CONCLUSIONS Although some studies in this updated review were adjudicated to have a high risk of bias, the results continue to support the key conclusion of our 2019 analysis: misoprostol-only is effective and safe for the termination of first-trimester intrauterine pregnancy. IMPLICATIONS Misoprostol-only is a safe and effective option for medication abortion in the first trimester if mifepristone is unavailable or inaccessible.
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Affiliation(s)
| | - Mark A Weaver
- Elon University, Department of Mathematics and Statistics, Elon, NC, United States
| | - Tara Shochet
- Gynuity Health Projects, New York, NY, United States
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Raymond EG, Weaver MA, Shochet T, Grant M, Boyd K, Koenig LR, Upadhyay U. Clinical outcomes of medication abortion using misoprostol-only: A retrospective chart review at an abortion provider organization in the United States. Contraception 2023; 126:110109. [PMID: 37390948 DOI: 10.1016/j.contraception.2023.110109] [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: 04/23/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVES This study aimed to evaluate the effectiveness and safety of medication abortion with misoprostol-only among patients treated by an abortion provider organization in the United States during the COVID-19 pandemic. STUDY DESIGN We abstracted data from patients receiving misoprostol-only for abortion from December 2020 to December 2021. Two regimens were used, both allowing three to four doses of misoprostol 800 mcg every 3 hours but differing in the recommended administration routes (vaginal, buccal, or sublingual). We estimated the proportions of patients who had complete abortion and ongoing pregnancy in the two regimen groups in complete case analyses and after imputing missing outcomes based on pretreatment characteristics. We also estimated maximum effectiveness, assuming that all patients without known treatment failures had complete abortions. We tabulated serious adverse events. RESULTS We ascertained abortion outcomes for 476 (52%) of the total 911 treated patients. Of the 476 patients, 389 (82%) had complete abortion confirmed by test or history, and 45 (9%) had ongoing pregnancies detected after the provision of treatment. These proportions did not differ significantly between the two regimen groups in adjusted complete case analyses (p > 0.44). The results of imputed analyses were similar. Of the total 911 patients, at most 90% (95% confidence interval 88%, 92%) had complete abortion, and at least 5% (95% confidence interval 4%, 7%) had ongoing pregnancy. Serious adverse events were reported in three patients (0.6% of 487 patients with data for this outcome). CONCLUSIONS Our analysis suggests that the misoprostol-only regimens studied were safe and effective for most patients. Due to high loss to follow-up, observations from patients contacted after treatment likely somewhat underestimate true effectiveness. IMPLICATIONS Medication abortion with misoprostol-only was safe and produced complete abortion in most patients with follow-up. If loss to follow-up is high, effectiveness observed by clinics may misestimate true treatment efficacy.
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Affiliation(s)
| | - Mark A Weaver
- Department of Mathematics and Statistics, Elon University, Elon, NC, United States.
| | - Tara Shochet
- Gynuity Health Projects, New York, NY, United States.
| | | | | | - Leah R Koenig
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Ushma Upadhyay
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States.
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Koenig LR, Raymond EG, Gold M, Boraas CM, Kaneshiro B, Winikoff B, Coplon L, Upadhyay UD. Mailing abortion pills does not delay care: A cohort study comparing mailed to in-person dispensing of abortion medications in the United States. Contraception 2023; 121:109962. [PMID: 36736715 PMCID: PMC10759792 DOI: 10.1016/j.contraception.2023.109962] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Given the substantial barriers to abortion access in the United States, many clinics now mail patients abortion medications. We examined whether dispensing the medications by mail prolonged time to medication use. STUDY DESIGN We analyzed data from no-test medication abortions with medication provided either by mail or in a clinic from 11 United States clinics from February 2020 to January 2021. We examined mean number of days from patients' first contact with the clinic to mifepristone ingestion, its two-component intervals (first contact to medication dispensing and dispensing to mifepristone ingestion), and pregnancy duration at mifepristone ingestion. We used Poisson regression to compare mean outcomes across three dispensing methods: in-person, mailed from the clinic, and mailed from a mail-order pharmacy. RESULTS Among the 2600 records, patients took mifepristone on average at 49 days of gestation (95% CI, 47-51) and 7 days (95% CI, 4-10) after first contact. Mean time from first contact to mifepristone ingestion was 6 days when medications were dispensed in-person and 9 days when mailed (p = 0.38). While time from first contact to dispensing was similar across methods (6 days in-person, 5 days mailed, p = 0.77), more time elapsed from dispensing to mifepristone ingestion when medications were mailed (4 days from clinic, 5 days from mail-order pharmacy) versus dispensed in-person (0.3 days, p < 0.001). Time to mifepristone ingestion was shorter with higher pregnancy duration. Pregnancy duration at ingestion was similar across methods (48 days in-person, 50 days mailed). CONCLUSIONS Mailing medications did not significantly prolong time from patients' first contact with the clinic to mifepristone ingestion or increase pregnancy duration at mifepristone ingestion. IMPLICATIONS Abortion providers should offer a range of medication abortion dispensing options, prioritizing patient preference.
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Affiliation(s)
- Leah R Koenig
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, Oakland, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA; Center for Gender and Health Justice, University of California Global Health Institute
| | | | - Marji Gold
- Department of Family and Social Medicine, Montefiore Medical Center, The Bronx, NY, USA
| | | | - Bliss Kaneshiro
- Deparment of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | | | | | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, Oakland, CA, USA; Center for Gender and Health Justice, University of California Global Health Institute.
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Anger H, Raymond EG. Implications of using Home Urine Pregnancy Tests vs. Facility-Based Tests for Assessment of Outcome Following Medication Abortion provided via Telemedicine. Contraception 2023:110055. [PMID: 37088124 DOI: 10.1016/j.contraception.2023.110055] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To assess whether planning high sensitivity urine pregnancy tests (HSPT) rather than facility-based tests for medication abortion follow-up may increase risk of unplanned clinical visits or procedural completion of the abortion. STUDY DESIGN We used data from the TelAbortion Project, a 5-year study assessing the safety and feasibility of providing mifepristone and misoprostol by telemedicine and mail in the United States. We categorized participants by whether the pre-treatment follow-up plan included HSPT at home 3-5 weeks after treatment or facility-based tests (ultrasound or serum HCG) within 2 weeks after treatment. We used multivariable logistic regression to compare likelihood of post-treatment unplanned, abortion-related clinical visits and procedural intervention in these groups. RESULTS Of 1,324 patients who planned HSPT follow-up and 576 who planned facility-based tests, 85% and 83%, respectively, provided outcome information. Post-treatment clinical visits were less frequent in the HSPT group (19%) than in the facility-based test group (79%); most of the latter were to obtain the planned test. However, unplanned, abortion-related visits were significantly more common in the HSPT group (adjusted risk difference: 6.5%; p<0.01). The likelihood of procedural completion did not differ by group. Planned follow-up test was not associated with delay in procedural completion or detection of ongoing pregnancy. CONCLUSIONS Follow-up of medication abortion with home HSPT was associated with fewer post-treatment clinical visits, modestly more unplanned, abortion-related clinical visits, and no increase in risk of procedural interventions or delayed identification or management of treatment failures. This option is an appropriate follow-up approach after medication abortion. IMPLICATIONS Use of home high-sensitivity pregnancy tests rather than facility-based tests for outcome assessment after medication abortion is associated with a modest increase in unplanned clinical visits but does not lead to an increase in procedural interventions or delays identification and management of treatment failure.
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Affiliation(s)
- Holly Anger
- Gynuity Health Projects; City University of New York Graduate School of Public Health and Health Policy
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Raymond EG, Mark A, Grossman D, Beasley A, Brandi K, Castle J, Creinin MD, Gerdts C, Gil L, Grant M, Lockley A, Perritt J, Shochet T, Truan D, Upadhyay UD. Medication abortion with misoprostol-only: A sample protocol. Contraception 2023; 121:109998. [PMID: 36849033 DOI: 10.1016/j.contraception.2023.109998] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 02/27/2023]
Affiliation(s)
| | - Alice Mark
- National Abortion Federation, Washington, DC, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
| | - Anitra Beasley
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | | | - Jen Castle
- Planned Parenthood Federation of America, New York, NY, USA
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | | | - Laura Gil
- Grupo Médico por el Derecho a Decidir-Colombia, Bogota, Colombia
| | | | - April Lockley
- Miscarriage and Abortion Hotline, Washington, DC, USA
| | | | | | | | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
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Frye LJ, Buhimschi IA, Raymond EG, Zhao G, Winikoff B. PAPP-A as a screening tool for assessment of gestational age before medication abortion in an intended-use population. Biomark Med 2023; 17:73-85. [PMID: 37038980 PMCID: PMC10183995 DOI: 10.2217/bmm-2022-0653] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/15/2023] [Indexed: 04/12/2023] Open
Abstract
Introduction: Prior studies indicate that PAPP-A could serve as a marker of gestational age (GA) with the potential to determine eligibility for medication abortion. The authors validated the relationship between PAPP-A and GA in an actual-use population. Materials & methods: The authors collected blood samples, medical histories and ultrasound-determined GA from patients presenting for abortion services. They measured PAPP-A using two immunoassays and assessed diagnostic accuracy for predicting GA ≥71 days. Results: The Ansh Labs and R&D Systems immunoassays produced an area under the ROC curve of 0.982 (95% CI: 0.958-0.994) and 0.986 (95% CI: 0.963-0.996), respectively, for predicting GA ≥71 days. Conclusion: This validation study in an intended-use population confirmed that PAPP-A has a strong ability to distinguish pregnancies above and below 71 days' gestation. Clinical trial registration: NCT04232189 (ClinicalTrials.gov).
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Affiliation(s)
- Laura J Frye
- Gynuity Health Projects, 220 East 42nd Street New York, NY 10017, USA
| | - Irina A Buhimschi
- Department of Obstetrics & Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612, USA
| | | | - Guomao Zhao
- Department of Obstetrics & Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612, USA
| | - Beverly Winikoff
- Gynuity Health Projects, 220 East 42nd Street New York, NY 10017, USA
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Ralph LJ, Ehrenreich K, Barar R, Biggs MA, Morris N, Blanchard K, Kapp N, Moayedi G, Perritt J, Raymond EG, White K, Grossman D. Accuracy of self-assessment of gestational duration among people seeking abortion. Am J Obstet Gynecol 2022; 226:710.e1-710.e21. [PMID: 34922922 DOI: 10.1016/j.ajog.2021.11.1373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/15/2021] [Accepted: 11/24/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Mifepristone, used together with misoprostol, is approved by the United States Food and Drug Administration for medication abortion through 10 weeks' gestation. Although in-person ultrasound is frequently used to establish medication abortion eligibility, previous research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using the date of their last menstrual period. OBJECTIVE In this study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations. STUDY DESIGN We surveyed patients seeking abortion at 7 facilities before ultrasound and compared self-assessments of gestational duration using 11 pregnancy dating questions with measurements on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating characteristic curve, sensitivity (or the proportion of ineligible participants who correctly screened as ineligible for medication abortion), and proportion of false negatives (ie, the proportion of all participants who erroneously screened as eligible for medication abortion). We tested for differences in sensitivity across individual and combined questions using McNemar's test, and for differences in accuracy using the area under the receiver operating curve and Sidak adjusted P values. RESULTS One-quarter (25%) of 1089 participants had a gestational duration of >70 days on ultrasound. Using the date of last menstrual period alone demonstrated 83.5% sensitivity (95% confidence interval, 78.4-87.9) in identifying participants with gestational durations of >70 days on ultrasound, with an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.79-0.85) and a proportion of false negatives of 4.0%. A composite measure of responses to questions on number of weeks pregnant, date of last menstrual period, and date they got pregnant demonstrated 89.1% sensitivity (95% confidence interval, 84.7-92.6) and an area under the receiver operating curve of 0.86 (95% confidence interval, 0.83-0.88), with 2.7% of false negatives. A simpler question set focused on being >10 weeks or >2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%; 95% confidence interval, 86.6-93.9) and proportion of false negatives (2.3%), but with a slightly lower area under the receiver operating curve (0.82; 95% confidence interval, 0.79-0.84). CONCLUSION In a sample representative of people seeking abortion nationally, broadening the screening questions for assessing gestational duration beyond the date of the last menstrual period resulted in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for medication abortion may not be necessary, especially when requiring ultrasound could increase COVID-19 risk or healthcare costs, restrict access, or limit patient choice.
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Upadhyay UD, Raymond EG, Koenig LR, Coplon L, Gold M, Kaneshiro B, Boraas CM, Winikoff B. Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study. JAMA Intern Med 2022; 182:482-491. [PMID: 35311911 PMCID: PMC8938895 DOI: 10.1001/jamainternmed.2022.0217] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care. OBJECTIVE To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US. EXPOSURES Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail. MAIN OUTCOMES AND MEASURES Effectiveness, defined as complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion. RESULTS The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%). CONCLUSIONS AND RELEVANCE In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco
| | | | - Leah R Koenig
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Marji Gold
- RHEDI/Montefiore Medical Center, Bronx, New York
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Buhimschi IA, Zhao G, El Helou Y, Frye LJ, Winikoff B, Raymond EG. Analytical Comparison of Pregnancy-Associated Plasma Protein-A (PAPP-A) Immunoassays for Biochemical Determination of Gestational Age. J Appl Lab Med 2021; 6:1517-1532. [PMID: 34329446 DOI: 10.1093/jalm/jfab057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Accurate pregnancy dating is critical for maternal and child health and for counseling on safe and effective abortion methods. While last menstrual period and first trimester ultrasound are often used together to determine gestational age (GA), they have limited accuracy and availability, respectively. Prior studies have shown that pregnancy-associated plasma protein-A (PAPP-A) increases exponentially during pregnancy and has the potential to serve as a biochemical marker of GA. We aimed to analyze the relationship between sonographically determined GA and serum PAPP-A concentration measured by different immunoassays and to derive cutoff levels informative for the 70 days GA commonly recommended limit for medical abortion in outpatient settings. METHODS We compared technical characteristics of 4 commercially available PAPP-A immunoassays and tested 120 maternal serum samples (GA range: 34-231 days) along with contrived pool samples and traceable quality controls. These characteristics included area under the receiver operator characteristic (AUROC) plot, sensitivity and specificity based on cutoffs defined by the Youden Index, and likelihood ratios. RESULTS All 4 immunoassays had sensitivities and specificities ≥80%, and AUROC values ranging from 0.948 to 0.968. Marked differences among absolute PAPP-A values were noted depending on immunoassay. PAPP-A cutoff values at 70 days GA for each individual immunoassay were established along with procedural recommendations that increase equivalence among immunoassays. CONCLUSIONS Maternal serum PAPP-A levels correlated strongly with GA despite differences in immunoassay formats and absolute data output. Serum PAPP-A has biomarker potential for future development of a point-of-care test aimed at increasing access to medical abortion.
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Affiliation(s)
- Irina A Buhimschi
- Department of Obstetrics & Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612
| | - Guomao Zhao
- Department of Obstetrics & Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612
| | - Yara El Helou
- Department of Obstetrics & Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL 60612
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Anger HA, Raymond EG, Grant M, Haskell S, Boraas C, Tocce K, Banks J, Coplon L, Shochet T, Platais I, Winikoff B. Clinical and service delivery implications of omitting ultrasound before medication abortion provided via direct-to-patient telemedicine and mail. Contraception 2021; 104:659-665. [PMID: 34329607 DOI: 10.1016/j.contraception.2021.07.108] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 06/01/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To compare outcomes among patients who did or did not have pre-abortion ultrasound or pelvic exam before obtaining medication abortion (MA) via direct-to-patient telemedicine and mail. STUDY DESIGN We analyzed data from participants screened for enrollment into the TelAbortion study at five sites from March 25 to September 15, 2020. We compared participants who had preabortion ultrasound or pelvic exam ("test-MA") to those who did not ("no-test MA"). Outcomes were: abortion not complete with pills alone (i.e., had procedure intervention or ongoing pregnancy), ongoing pregnancy separately, ectopic pregnancy, hospitalization and/or blood transfusion, and unplanned clinical encounters. We used propensity score weighting and multivariable logistic regression to adjust for baseline characteristics. RESULTS Our analysis included 287 participants who had no-test MA and 125 who had test-MA. Abortion was not complete with pills alone in 16of 287 (5.6%) no-test MA patients compared to 2of 123 (1.9%) test-MA patients (adjusted risk difference [aRD] = 4.3%, 95% confidence interval [CI]: 1.4%-7.1%). No ectopic pregnancies were detected. Groups did not differ regarding hospitalization and/or blood transfusion (p = 0.76) or ongoing pregnancy diagnosis (p = 0.59). Unplanned clinical encounters were more common in no-test MA patients (35of 287, 12.5%) than test-MA patients (10of 125, 8.0%, aRD = 6.7%, 95% CI: 0.5%-13.1%). CONCLUSIONS Compared to patients who had pre-abortion ultrasound, patients who had no-test MA via telemedicine were more likely to have abortions that were not complete with pills alone and/or unplanned clinical encounters. However, both no-test and test-MA patients had similar and very low rates of ongoing pregnancy and hospitalization or blood transfusion. IMPLICATIONS Omitting pre-abortion ultrasound before provision of medication abortion via telemedicine does not appear to compromise safety or result in more ongoing pregnancies. However, compared to patients who have preabortion ultrasound, patients who do not have pre-abortion tests may be more likely to seek post-treatment care and have procedural interventions.
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Affiliation(s)
- Holly A Anger
- Gynuity Health Projects, New York, NY, United States.
| | | | | | | | - Christy Boraas
- Planned Parenthood of the North Central States, St. Paul MN, United States
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, CO, United States
| | - Joey Banks
- Planned Parenthood of Montana, Billings, MT, United States
| | - Leah Coplon
- Maine Family Planning, Augusta, ME, United States
| | - Tara Shochet
- Gynuity Health Projects, New York, NY, United States
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Raymond EG, Anger HA, Chong E, Haskell S, Grant M, Boraas C, Tocce K, Banks J, Kaneshiro B, Baldwin MK, Coplon L, Bednarek P, Shochet T, Platais I. "False positive" urine pregnancy test results after successful medication abortion. Contraception 2021; 103:400-403. [PMID: 33596414 DOI: 10.1016/j.contraception.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To examine the proportion of high-sensitivity urine pregnancy test (HSPT) results that were positive by time after successful medication abortion. STUDY DESIGN We used data from an ongoing study that provides mifepristone and misoprostol for medication abortion by direct-to-patient telemedicine and mail. Providers evaluated abortion outcomes by patient interview and clinical tests per clinical judgment and participant preference. We identified all participants enrolled July 2016 to September, 2020 who had an HSPT result and no indication of viable pregnancy after treatment. We used logistic regression to examine the association between the timing of the initial post-treatment HSPT, gestational age, and the proportion of HSPTs that gave a positive result. RESULTS Of the 472 participants in our analysis, 88 (19%) had positive initial HSPTs. The proportions that were positive at ≤20 days, 21 to 27 days, 28 to 34 days, and ≥35 days after mifepristone ingestion was 14 of 29 (48%), 15 of 58 (26%), 49 of 258 (19%), and 10 of 127 (8%), respectively (p < 0.001). Gestational age at mifepristone ingestion was not significantly related to positive HSPT results (p = 0.28). Multivariable logistic regression confirmed both findings and did not identify a statistically significant interaction between these variables. In the 67 participants who relied solely on further HSPTs to confirm abortion outcome, the median interval between the initial positive test and first negative test was 14 days. CONCLUSIONS The proportion of participants with positive HSPTs declined with time after successful medication abortion. However, nearly one-fifth of participants with complete abortion had positive tests 4 weeks after treatment. IMPLICATIONS HSPTs provide an inexpensive, convenient option for confirming success of medication abortion at home. However, a substantial minority of patients without ongoing pregnancy have positive HSPT results. Development of a symptom-based strategy for medication abortion outcome assessment without any confirmatory tests should be a priority.
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Affiliation(s)
| | | | - Erica Chong
- Gynuity Health Projects, New York, NY, USA; Reproductive Health Education In Family Medicine, Bronx, NY, USA
| | | | | | - Christy Boraas
- Planned Parenthood of the North Central States, St. Paul, MN, USA
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, CO, USA
| | - Joey Banks
- Planned Parenthood of Montana, Billings, MT, USA
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | | | | | - Paula Bednarek
- Oregon Health & Science University, Portland, OR, USA; Planned Parenthood Columbia Willamette, Portland, OR, USA
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Raymond EG, Frye LJ, Weaver MA, Lebed JP, Ren X, Steider E, Winikoff B, Barnhart KT. Sensitivity and specificity of placental proteins for gestational age screening: An exploratory study. Contraception 2020; 101:309-314. [DOI: 10.1016/j.contraception.2020.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/07/2020] [Accepted: 01/15/2020] [Indexed: 11/29/2022]
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Raymond EG, Grossman D, Mark A, Upadhyay UD, Dean G, Creinin MD, Coplon L, Perritt J, Atrio JM, Taylor D, Gold M. Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception 2020; 101:361-366. [PMID: 32305289 PMCID: PMC7161512 DOI: 10.1016/j.contraception.2020.04.005] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/05/2022]
Affiliation(s)
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, United States.
| | - Alice Mark
- National Abortion Federation, Washington DC, United States.
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, United States.
| | - Gillian Dean
- Planned Parenthood Federation of America, New York, NY, United States.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Leah Coplon
- Maine Family Planning, Augusta, ME, United States.
| | - Jamila Perritt
- Reproductive Health and Family Planning Specialist, Washington DC, United States
| | - Jessica M Atrio
- Society of Family Planning, Clinical Affairs Subcommittee and Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY, United States.
| | - DeShawn Taylor
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine Phoenix, AZ, United States.
| | - Marji Gold
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, United States.
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Hyland P, Raymond EG, Chong E. A direct-to-patient telemedicine abortion service in Australia: Retrospective analysis of the first 18 months. Aust N Z J Obstet Gynaecol 2018; 58:335-340. [DOI: 10.1111/ajo.12800] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 02/15/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Paul Hyland
- Tabbot Foundation; Sydney New South Wales Australia
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Raymond EG, Tan YL, Comendant R, Sagaidac I, Hodorogea S, Grant M, Sanhueza P, Van Pratt E, Gillespie G, Boraas C, Weaver MA, Platais I, Bousieguez M, Winikoff B. Simplified medical abortion screening: a demonstration project. Contraception 2017; 97:292-296. [PMID: 29170088 DOI: 10.1016/j.contraception.2017.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/06/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The objectives were to evaluate the safety and acceptability of outpatient medical abortion in selected women without a pretreatment ultrasound or pelvic examination. STUDY DESIGN We conducted a prospective case-series study to estimate the incidence of serious adverse events (death, life-threatening event, hospitalization, transfusion or any other medical problem that we judged to be significant), surgical completion of the abortion and satisfaction in women provided with medical abortion without a pretreatment ultrasound or pelvic examination. We enrolled 406 women requesting medical abortion in Moldova, Mexico and the United States. To be eligible, a woman must have been certain that her last menstrual period started within the prior 56days, have had regular menses before the pregnancy, not have used hormonal contraceptives in the prior 2months (in the United States and Mexico) or 3months (in Moldova), have no risk factors for or symptoms of ectopic pregnancy, and not have had an ultrasound or pelvic exam in this pregnancy. One site also excluded women with uterine enlargement on abdominal palpation. Each participant received mifepristone (200mg orally) and misoprostol (400 mcg sublingually in Moldova; 800 mcg buccally at all other sites) and was followed until complete abortion, defined as requiring no further treatment. RESULTS Of the 365 (90%) participants who provided sufficient follow-up information for analysis, 347 (95%) had complete abortion without additional treatment, 5 (1%) had surgical aspiration, and 10 (3%) had extra misoprostol. Three participants (1%) had serious adverse events; these included two hospital admissions for heavy bleeding managed with aspiration and one diagnosis of persistent gestational sac 19days after enrollment. Most (317, 90%) participants were pleased with omitting the pretreatment ultrasound and pelvic exam. CONCLUSIONS In this study, medical abortion without screening ultrasound or pelvic exam resulted in no serious adverse events that were likely to have been prevented by those tests and was highly acceptable. IMPLICATIONS Screening for medical abortion without exam or ultrasound shows promise as a means for increasing access to this service. More research is needed to develop screening criteria that are more inclusive and simpler for clinical use.
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Affiliation(s)
| | - Yi-Ling Tan
- Gynuity Health Projects, New York, NY 10010, USA
| | - Rodica Comendant
- Reproductive Health Training Center, Moldova; "Nicolae Testemitanu" State University of Medicine and Pharmacy of the Republic of Moldova, Department Obstetrics and Gynecology, PhD
| | - Irina Sagaidac
- Reproductive Health Training Center, Moldova; "Nicolae Testemitanu" State University of Medicine and Pharmacy of the Republic of Moldova, Department Obstetrics and Gynecology, PhD
| | - Stelian Hodorogea
- Reproductive Health Training Center, Moldova; "Nicolae Testemitanu" State University of Medicine and Pharmacy of the Republic of Moldova, Department Obstetrics and Gynecology, PhD
| | | | | | | | | | - Christy Boraas
- Planned Parenthood Minnesota, North Dakota, South Dakota, Minneapolis, MN
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Murtagh C, Wells E, Raymond EG, Coeytaux F, Winikoff B. Exploring the feasibility of obtaining mifepristone and misoprostol from the internet. Contraception 2017; 97:287-291. [PMID: 29030227 DOI: 10.1016/j.contraception.2017.09.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We aimed to document the experience of buying abortion pills from online vendors that do not require a prescription and to evaluate the active ingredient content of the pills received. STUDY DESIGN We searched the internet to identify a convenience sample of websites that sold mifepristone and misoprostol to purchasers in the United States and attempted to order these products. We documented price, shipping time and other aspects of ordering. We sent the samples received to a testing laboratory that measured the amount of active ingredient in individual tablets. RESULTS We identified 18 websites and ordered 22 products: 20 mifepristone-misoprostol combination products and 2 that contained only misoprostol. We received 18 combination products and the 2 misoprostol products from 16 different sites. No site required a prescription or any relevant medical information. The time between order and receipt of the 20 products ranged from 3 to 21 business days (median 9.5 days). The price for the 18 combination products ranged from $110 to $360, including shipping and fees; the products without mifepristone cost less. Chemical assays found that the 18 tablets labeled 200 mg mifepristone contained between 184.3 mg and 204.1 mg mifepristone, while the 20 tablets labeled 200 mcg misoprostol contained between 34.1 mcg and 201.4 mcg of the active ingredient. CONCLUSIONS Obtaining abortion medications from online pharmaceutical websites is feasible in the United States. The mifepristone tablets received contained within 8% of the labeled amount of active agent. The misoprostol tablets all contained that compound but usually less than labeled. IMPLICATIONS STATEMENT Given our findings, we expect that some people for whom clinic-based abortion is not easily available or acceptable may consider self-sourcing pills from the internet to be a rational option.
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Affiliation(s)
- Chloe Murtagh
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
| | - Elisa Wells
- Plan C, c/o National Women's Health Network, 1413 K Street NW, 4th Floor, Washington, D.C. 20005
| | - Elizabeth G Raymond
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Francine Coeytaux
- Plan C, c/o National Women's Health Network, 1413 K Street NW, 4th Floor, Washington, D.C. 20005
| | - Beverly Winikoff
- Gynuity Health Projects, 15 East 26th Street, Suite 801, New York, NY, 10010, USA
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Raymond EG, Shochet T, Blum J, Sheldon WR, Platais I, Bracken H, Dabash R, Weaver MA, Ngoc NTN, Blumenthal PD, Winikoff B. Serial multilevel urine pregnancy testing to assess medical abortion outcome: a meta-analysis. Contraception 2017; 95:442-448. [DOI: 10.1016/j.contraception.2016.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 01/21/2023]
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Raymond EG, Blanchard K, Blumenthal PD, Cleland K, Foster AM, Gold M, Grossman D, Pendergast MK, Westhoff CL, Winikoff B. Sixteen Years of Overregulation: Time to Unburden Mifeprex. N Engl J Med 2017; 376:790-794. [PMID: 28225670 DOI: 10.1056/nejmsb1612526] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | - Paul D Blumenthal
- Division of Family Planning Services and Research, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA
| | - Kelly Cleland
- Office of Population Research, Princeton University, Princeton, NJ
| | - Angel M Foster
- Faculty of Health Sciences, University of Ottawa, Ottawa
| | - Marji Gold
- Albert Einstein College of Medicine, Bronx, NY
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA
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Raymond EG, Bracken H. Early medical abortion without prior ultrasound. Contraception 2015; 92:212-4. [DOI: 10.1016/j.contraception.2015.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/15/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
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Abbas D, Chong E, Raymond EG. Outpatient medical abortion is safe and effective through 70days gestation. Contraception 2015; 92:197-9. [DOI: 10.1016/j.contraception.2015.06.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 06/19/2015] [Accepted: 06/21/2015] [Indexed: 11/29/2022]
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Raymond EG, Coeytaux F, Gemzell-Danielsson K, Moore K, Trussell J, Winikoff B. Embracing post-fertilisation methods of family planning: a call to action. ACTA ACUST UNITED AC 2015; 39:244-6. [PMID: 24062495 DOI: 10.1136/jfprhc-2013-100702] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 11/04/2022]
Abstract
Family planning methods that act when administered after fertilisation would have substantial benefits: they could be used longer after sex than current emergency contraceptives, and potentially a woman could use them only on relatively rare occasions when her menstrual period is delayed. Although such methods would displease abortion opponents, they would likely be welcomed by many women. Research to develop post-fertilisation fertility control agents should be pursued.
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Raymond EG, Grossman D, Wiebe E, Winikoff B. Reaching women where they are: eliminating the initial in-person medical abortion visit. Contraception 2015; 92:190-3. [PMID: 26134280 DOI: 10.1016/j.contraception.2015.06.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/22/2015] [Accepted: 06/23/2015] [Indexed: 10/23/2022]
Abstract
The requirement that every woman desiring medical abortion must come in person to a clinical facility to obtain the drugs is a substantial barrier for many women. To eliminate this requirement in the United States, two key components of the standard initial visit would need to be restructured. First, alternatives to ultrasound and pelvic exam would need to be identified for ensuring that gestational age is within the limit for safe and effective treatment. This is probably feasible: for example, data from a large study suggest that in selected patients menstrual history is highly sensitive for this purpose. Second, the Food and Drug Administration would need to remove the medically unwarranted restriction on distribution of mifepristone. These two changes could allow provision of the service by a broader range of providers in nontraditional venues or even by telemedicine. Such options could have profound benefits in reducing cost and expanding access to abortion.
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Affiliation(s)
- Elizabeth G Raymond
- Gynuity Health Projects, 15 E 26th Street, Suite 801, New York, NY, 10010, USA.
| | - Daniel Grossman
- Ibis Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, CA, USA.
| | - Ellen Wiebe
- Department of Family Practice, University of British Columbia and Medical Director, Willow Women's Clinic, Vancouver, British Columbia, Canada.
| | - Beverly Winikoff
- Gynuity Health Projects, 15 E 26th Street, Suite 801, New York, NY, 10010, USA.
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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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Abstract
BACKGROUND Repeated use of postcoital hormonal contraception is not currently recommended due to the higher risk of side effects and lower contraceptive effectiveness compared to other modern methods of contraception. However, emerging evidence indicates renewed interest in a regular coitally-dependent method of oral contraception. We evaluated the existing data on safety and effectiveness of pericoital use of levonorgestrel and other hormonal drugs to prevent pregnancy. OBJECTIVES To determine the effectiveness and safety of repeated use of pre- and postcoital hormonal contraception for pregnancy prevention. SEARCH METHODS We searched until 1 September 2014 for trials that tested repeated pre- and postcoital use of hormonal drugs for pregnancy prevention. Databases included CENTRAL, MEDLINE, and POPLINE. We searched for current trials via ClinicalTrials.gov and ICTRP. For the initial review, we also searched EMBASE, CINAHL, and LILACS, and wrote to researchers to identify other trials. SELECTION CRITERIA We considered published and unpublished studies of repeated postcoital or immediately precoital use of hormonal drugs for contraception with pregnancy as an outcome. DATA COLLECTION AND ANALYSIS Two authors independently confirmed eligibility and extracted data from the included studies. We calculated confidence intervals (CI) around individual study Pearl indices using a Poisson distribution. We presented individual study estimates and pooled estimates and their 95% CI, where appropriate. MAIN RESULTS We found 22 trials that evaluated pericoital use of LNG and other hormonal drugs on a regular basis to prevent pregnancy. The studies included a total of 12,400 participants, and were conducted in Europe, Asia, and the Americas. The drugs and doses evaluated included levonorgestrel (LNG) 0.75 mg (11 studies), LNG in doses other than 0.75 mg (4 trials), and hormones other than LNG (7 trials). Outcomes included pregnancy rates, discontinuation, side effects, and acceptability.Pericoital levonorgestrel was reasonably efficacious and safe. The pooled Pearl Index for the 0.75 mg dose of LNG was 5.4 per 100 woman-years (95% CI 4.1 to 7.0). The pooled Pearl Index for all doses of LNG was 5.0 per 100 woman-years (95% CI 4.4 to 5.6). Other hormonal drugs appeared promising but most of them were not studied extensively. Menstrual irregularities were the most common side effects reported. However, the studies provided no consistent evidence of a relationship between bleeding abnormalities and either frequency of pill intake or total dose of the drug. Non-menstrual side effects were reportedly mild and not tabulated in most studies. Most women liked the pericoital method in spite of frequent menstrual irregularities. AUTHORS' CONCLUSIONS The studies of pericoital LNG regimens provided promising results but many had serious methodological issues. Most reports were decades old and provided limited information. However, we considered the evidence to be moderate quality because of the large number of participants from diverse populations, the low pregnancy rates, and the consistent results across studies. Rigorous research is still needed to confirm the efficacy and safety of pericoital use of LNG as a primary means of contraception among women with infrequent intercourse. If the method is shown to be efficacious, safe and acceptable, the results may warrant revision of the current World Health Organization recommendations and marketing strategies.
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Affiliation(s)
- Vera Halpern
- FHI 360Clinical Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
| | | | - Laureen M Lopez
- FHI 360Clinical Sciences359 Blackwell St, Suite 200DurhamNorth CarolinaUSA27701
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Raymond EG, Shochet T, Drake JK, Westley E. What some women want? On-demand oral contraception. Contraception 2014; 90:105-10. [DOI: 10.1016/j.contraception.2014.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 04/10/2014] [Accepted: 04/15/2014] [Indexed: 11/24/2022]
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Raymond EG, Trussell J, Gemzell-Danielsson K. Comment on 'Embracing post-fertilisation methods of family planning: a call to action': authors' response. J Fam Plann Reprod Health Care 2013; 40:73-4. [PMID: 24347589 DOI: 10.1136/jfprhc-2013-100825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
BACKGROUND Spermicides have been used as contraceptives for thousands of years. Despite this long use, only recently have studies examined the comparative efficacy and acceptability of these vaginal medications. Spermicides contain an active ingredient (most commonly nonoxynol-9) and a formulation used to disperse the product, such as foam or vaginal suppository. OBJECTIVES This review examined all known randomized controlled trials of a spermicide used alone for contraception. SEARCH METHODS In August 2013, we searched the following computerized databases for randomized controlled trials of spermicides for contraception: CENTRAL, MEDLINE, POPLINE, LILACS, EMBASE, ClinicalTrials.gov, and ICTRP. For the initial review, we examined the reference lists of trials found as well as those of review articles and textbook chapters. SELECTION CRITERIA We included any trial of a commercial product used alone for contraception. Each included trial must have provided sufficient information to determine pregnancy rates. DATA COLLECTION AND ANALYSIS Two authors independently extracted information from the trials identified. We did not conduct a meta-analysis, since most trials had large losses to follow up. We entered the data into tables and presented the results descriptively. MAIN RESULTS We located reports from 14 trials for the initial review, but have not identified any new trials since then. In the largest trial to date, the gel (Advantage S) containing the lowest dose of nonoxynol-9 (52.5 mg) was significantly less effective in preventing pregnancy than were gels with higher doses of the same agent (100 mg and 150 mg). Probabilities of pregnancy by six months were 22% for the 52.5 mg gel, 16% for the 100 mg dose, and 14% for the 150 mg dose. In the same trial, the three different vehicles with 100 mg of nonoxynol-9 had similar efficacy. Interpretation of these figures is limited, since 39% of participants discontinued the method or were lost from the trial. Few important differences in efficacy emerged in other trials. AUTHORS' CONCLUSIONS The probability of pregnancy varied widely in reported trials. A gel containing nonoxynol-9 52.5 mg was inferior to two other products tested in the largest trial. Aside from this finding, personal characteristics and behavior of users may be more important than characteristics of the spermicide products in determining the probability of pregnancy. Gel was liked more than the film or vaginal suppository in the largest trial. Spermicide trials have the dual challenges of difficult recruitment and high discontinuation rates; the latter threatens trial validity.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
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Taylor DJ, Lendvay A, Halpern V, Bahamondes LG, Fine PM, Ginde SY, Wheeless A, Raymond EG. A single-arm study to evaluate the efficacy, safety and acceptability of pericoital oral contraception with levonorgestrel. Contraception 2013; 89:215-21. [PMID: 24388695 DOI: 10.1016/j.contraception.2013.11.013] [Citation(s) in RCA: 6] [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] [Received: 07/04/2013] [Revised: 11/08/2013] [Accepted: 11/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND An oral dose of 0.75 mg levonorgestrel (LNG) taken shortly after sex was marketed as a routine, nonemergency contraceptive method until the 1990s. Because a hormonal method used only at the time of intercourse may be desirable for women who have infrequent sex, we conducted a study to reevaluate the potential of pericoital LNG as a primary means of contraception. METHODS We enrolled women aged 18-45 years in Brazil and the USA who expected to have sex 1-4 days per month for 6.5 months. Participants were instructed to take one tablet 0.75 mg LNG within 24 h before or after sex, with no more than one dose in any 24-h period. The primary efficacy measure was the Pearl Index among women aged 18-35 years. RESULTS The study was stopped after 72 of the planned 300 participants were enrolled due to slow recruitment and related feasibility considerations. In the primary analysis, three pregnancies occurred during 13.4 woman-years of follow-up, resulting in a Pearl Index of 22.4 (95% confidence interval, 4.6-65.4). No serious adverse events were reported, and vaginal bleeding patterns were generally acceptable. CONCLUSIONS Our estimated Pearl Index was noticeably higher than expected from previous research of LNG for pericoital contraception. Although the regimen was safe and generally acceptable, the study was challenged by slow enrollment and curtailed person-years of follow-up, resulting in poor precision for the estimated treatment effect. Future research may inform whether our results are symptomatic of the regimen, study design or characteristics of the populations from which we recruited. IMPLICATIONS Our study failed to confirm prior data suggesting that 0.75 mg LNG for pericoital contraception could be more effective than typical use of barrier methods among women having infrequent sex. Characterizing populations most likely to adhere to, and benefit from, pericoital regimens is essential to future research on these methods.
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Affiliation(s)
| | - Anja Lendvay
- FHI 360, 2224 E NC HWY 54, Durham, NC 27713, USA
| | - Vera Halpern
- FHI 360, 2224 E NC HWY 54, Durham, NC 27713, USA.
| | - Luis G Bahamondes
- Human Reproductive Unit, Department of Obstetrics and Gynecology, School of Medicine, University of Campinas, Campinas, Brazil
| | - Paul M Fine
- Planned Parenthood Gulf Coast, Inc. , 4600 Gulf Freeway Houston, TX 77023-3533, USA
| | - Savita Y Ginde
- Planned Parenthood of the Rocky Mountains, Denver, CO 80207, USA
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Abstract
BACKGROUND The introduction of a new progestin-only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. OBJECTIVES This review examined randomized controlled trials of progestin-only pills for differences in efficacy, acceptability, and continuation rates. SEARCH METHODS Through October 2013, we searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and LILACS for studies of progestin-only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. SELECTION CRITERIA We included all randomized controlled trials in any language that included progestin-only pills for contraception. We incorporated any comparison with a progestin-only pill; this could include different doses, other progestin-only pills, combined oral contraceptives, or other contraceptives. DATA COLLECTION AND ANALYSIS The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry.We attempted to extract life-table rates (actuarial or continuous) and used the rate difference as the effect measure. Where life-table rates were not published, we used the incidence rate ratio (ratio of Pearl rates). Where only the crude number of events was published, we calculated the Peto odds ratio with 95% confidence interval (CI) using a fixed-effect model. For continuous variables, the mean difference (MD) was computed with 95% CI. Because of disparate exposures, we were not able to combine studies in meta-analysis. MAIN RESULTS Six trials met the inclusion criteria. We have not found any new studies since the initial review. In the trial comparing the desogestrel versus levonorgestrel progestin-only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin-only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low-dose mifepristone versus a levonorgestrel progestin-only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin-only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin-only and two combined oral contraceptives, the progestin-only pill containing levonorgestrel 30 μg had higher efficacy than did the pill containing norethisterone 350 μg. An early trial found megestrol acetate inferior to other progestin-only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. AUTHORS' CONCLUSIONS Evidence is insufficient to compare progestin-only pills to each other or to combined oral contraceptives.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
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Abstract
BACKGROUND Spermicides have been used as contraceptives for thousands of years. Despite this long use, only recently have studies examined the comparative efficacy and acceptability of these vaginal medications. Spermicides contain an active ingredient (most commonly nonoxynol-9) and a formulation used to disperse the product, such as foam or vaginal suppository. OBJECTIVES This review examined all known randomized controlled trials of a spermicide used alone for contraception. SEARCH METHODS In August 2013, we searched the following computerized databases for randomized controlled trials of spermicides for contraception: CENTRAL, MEDLINE, POPLINE, LILACS, EMBASE, ClinicalTrials.gov, and ICTRP. For the initial review, we examined the reference lists of trials found as well as those of review articles and textbook chapters. SELECTION CRITERIA We included any trial of a commercial product used alone for contraception. Each included trial must have provided sufficient information to determine pregnancy rates. DATA COLLECTION AND ANALYSIS Two authors independently extracted information from the trials identified. We did not conduct a meta-analysis, since most trials had large losses to follow up. We entered the data into tables and presented the results descriptively. MAIN RESULTS We located reports from 14 trials for the initial review, but have not identified any new trials since then. In the largest trial to date, the gel (Advantage S) containing the lowest dose of nonoxynol-9 (52.5 mg) was significantly less effective in preventing pregnancy than were gels with higher doses of the same agent (100 mg and 150 mg). Probabilities of pregnancy by six months were 22% for the 52.5 mg gel, 16% for the 100 mg dose, and 14% for the 150 mg dose. In the same trial, the three different vehicles with 100 mg of nonoxynol-9 had similar efficacy. Interpretation of these figures is limited, since 39% of participants discontinued the method or were lost from the trial. Few important differences in efficacy emerged in other trials. AUTHORS' CONCLUSIONS The probability of pregnancy varied widely in reported trials. A gel containing nonoxynol-9 52.5 mg was inferior to two other products tested in the largest trial. Aside from this finding, personal characteristics and behavior of users may be more important than characteristics of the spermicide products in determining the probability of pregnancy. Gel was liked more than the film or vaginal suppository in the largest trial. Spermicide trials have the dual challenges of difficult recruitment and high discontinuation rates; the latter threatens trial validity.
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Affiliation(s)
- David A Grimes
- Obstetrics and Gynecology, University of North Carolina, School of Medicine, CB#7570, Chapel Hill, North Carolina, USA, 27599-7570
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Raymond EG, Shannon C, Weaver MA, Winikoff B. First-trimester medical abortion with mifepristone 200 mg and misoprostol: a systematic review. Contraception 2013; 87:26-37. [DOI: 10.1016/j.contraception.2012.06.011] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 06/15/2012] [Accepted: 06/19/2012] [Indexed: 11/30/2022]
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Grimes DA, Stuart GS, Raymond EG. Feticidal digoxin injection before dilation and evacuation abortion. Contraception 2012; 85:140-3. [DOI: 10.1016/j.contraception.2011.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
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Raymond EG, Ramchandani P, Shaunik A, Lendvay A, Sokal D, Barnhart KT. Exploration of a new procedure for sterilization by intrauterine instillation of a methylcellulose gel. Contraception 2011; 83:263-7. [PMID: 21310289 DOI: 10.1016/j.contraception.2010.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 07/21/2010] [Accepted: 07/22/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Our goal was to evaluate a new gel and procedure for non-surgical sterilization. STUDY DESIGN We injected a methylcellulose-based gel containing a radiographic contrast agent into the uteri of 15 women, varying the gel viscosity, volume injected, injection speed and continuity and duration of cervical blockage. We monitored gel distribution with fluoroscopy and spot imaging, and subjects' condition by interview and examination. RESULTS The gel and procedure were safe and acceptable. The low-viscosity gel reached at least the ampullae of all tubes, but retention in the isthmuses was shorter than 5 min in more than 25% of tubes studied. The high-viscosity gel did not consistently pass into and through the fallopian tubes. CONCLUSIONS This study did not identify a gel and insertion procedure that would reliably provide exposure of both fallopian tubes to a sclerosing agent for more than a brief period of time.
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Polis CB, Raymond EG, Trussell J. Facing the facts on advance provision of emergency contraception. Contraception 2010; 82:579-80; author reply 579. [PMID: 21074023 DOI: 10.1016/j.contraception.2010.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
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Grimes DA, Schulz KF, Raymond EG. Surrogate end points in women's health research: science, protoscience, and pseudoscience. Fertil Steril 2010; 93:1731-4. [DOI: 10.1016/j.fertnstert.2009.12.054] [Citation(s) in RCA: 25] [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] [Received: 11/12/2009] [Revised: 12/21/2009] [Accepted: 12/22/2009] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Repeated use of postcoital hormonal contraception is not currently recommended due to the higher risk of side effects and lower contraceptive effectiveness compared to other modern methods of contraception. However, emerging evidence indicates renewed interest in a regular coitally-dependent method of oral contraception. We re-evaluated the existing data on safety and effectiveness of pericoital use of levonorgestrel and other hormonal drugs to prevent pregnancy. OBJECTIVES To determine the effectiveness and safety of repeated use of pre- and postcoital hormonal contraception for pregnancy prevention SEARCH STRATEGY We searched the computerized databases MEDLINE, POPLINE, CINAHL, LILACS, EMBASE and CENTRAL for trials that tested repeated pre- and postcoital use of hormonal drugs for pregnancy prevention. We also searched for current trials via ClinicalTrials.gov and ICTRP. SELECTION CRITERIA Published and unpublished studies in any language of repeated postcoital or immediately precoital use of hormonal drugs for contraception with pregnancy as an outcome DATA COLLECTION AND ANALYSIS Two authors independently confirmed the eligibility and extracted data from the included studies. We calculated confidence intervals (CI) around individual study Pearl indices using a Poisson distribution. We presented individual study estimates and pooled estimates and their 95% CI, where appropriate. MAIN RESULTS We found 21 trials that evaluated pericoital use of LNG and other hormonal drugs on a regular basis to prevent pregnancy. Pericoital levonorgestrel (LNG) was reasonably efficacious and safe. The pooled Pearl Index for the 0.75 mg dose of LNG was 5.1 per 100 woman-years (WY) (95% CI 3.8 to 6.7). The pooled Pearl Index for all doses of LNG was 4.9 per 100 WY (95% CI 4.3 to 5.5). Other hormonal drugs appeared promising but most of them were not studied extensively. Most women liked the pericoital method in spite of frequent menstrual irregularities. AUTHORS' CONCLUSIONS The studies of pericoital LNG regimens provided promising results but had a number of serious methodological limitations. A pressing need exits to conduct a rigorous research to confirm the efficacy and safety of pericoital use of LNG as a primary means of contraception among women with infrequent intercourse. If the method is shown to be efficacious, safe and acceptable, the results may warrant revision of the current WHO recommendations and marketing strategies.
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Affiliation(s)
- Vera Halpern
- Behavioral and Biomedical Research, Family Health International, PO Box 13950, Research Triangle Park, North Carolina, USA, NC 27709
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42
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Abstract
BACKGROUND The introduction of a new progestin-only oral contraceptive in Europe has renewed interest in this class of oral contraceptives. Unlike the more widely used combined oral contraceptives containing an estrogen plus progestin, these pills contain only a progestin (progestogen) and are taken without interruption. How these pills compare to others in their class or to combined oral contraceptives is not clear. OBJECTIVES This review examined randomized controlled trials of progestin-only pills for differences in efficacy, acceptability, and continuation rates. SEARCH STRATEGY We searched the computerized databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, LILACS, and EMBASE for studies of progestin-only pills. We also searched for current trials via ClinicalTrials.gov and ICTRP. SELECTION CRITERIA We included all randomized controlled trials in any language that included progestin-only pills for contraception. We incorporated any comparison with a progestin-only pill; this could include different doses, other progestin-only pills, combined oral contraceptives, or other contraceptives. DATA COLLECTION AND ANALYSIS The first author abstracted the data and entered the information into RevMan 5. Another author performed a second, independent data abstraction to verify the initial data entry. Because of disparate exposures, we were not able to combine studies in meta-analysis. MAIN RESULTS Six trials met the inclusion criteria. In the trial comparing the desogestrel versus levonorgestrel progestin-only pill, desogestrel was not associated with a significantly lower risk of accidental pregnancy; the rate ratio was 0.27 (95% CI 0.06 to 1.19). However, the desogestrel progestin-only pill caused more bleeding problems, although this difference was not statistically significant. The trial comparing low-dose mifepristone versus a levonorgestrel progestin-only pill found similar pregnancy rates. In the trial comparing ethynodiol diacetate versus a combined oral contraceptive, irregular cycles occurred in all women assigned to the progestin-only pill (odds ratio 135.96; 95% CI 7.61 to 2421.02). In a trial comparing two progestin-only and two combined oral contraceptives, the progestin-only pill containing levonorgestrel 30 mug had higher efficacy than did the pill containing norethisterone 350 mug. An early trial found megestrol acetate inferior to other progestin-only pills in terms of efficacy. A study of the timing of pill initiation after birth found no important differences, but high losses to follow up undermined the trial. AUTHORS' CONCLUSIONS Evidence is insufficient to compare progestin-only pills to each other or to combined oral contraceptives.
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Affiliation(s)
- David A Grimes
- Behavioral and Biomedical Research, Family Health International, PO Box 13950, Research Triangle Park, North Carolina, USA, NC 27709
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Sander PM, Raymond EG, Weaver MA. Emergency contraceptive use as a marker of future risky sex, pregnancy, and sexually transmitted infection. Am J Obstet Gynecol 2009; 201:146.e1-6. [PMID: 19646565 DOI: 10.1016/j.ajog.2009.05.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Revised: 04/03/2009] [Accepted: 05/12/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of the study was to examine whether emergency contraceptive use predicts future sex at risk for pregnancy, pregnancy, or sexually transmitted infection among young women. STUDY DESIGN A secondary analysis of control group participants (n = 718) from a recent trial of advanced provision of emergency contraception was conducted. RESULTS We found no association between use of emergency contraception and either pregnancy or infection. Recent use predicted decreased occurrence of subsequent sex at risk for pregnancy among women with a history of sexually transmitted infection (relative risk [RR], 0.39; 95% confidence interval [CI], 0.15-0.97), whereas ever having used predicted increased occurrence among women who either were highly effective method users (RR, 1.45; 95% CI, 1.05-2.01) or had no history of sexually transmitted infection (RR, 1.31; 95% CI, 1.04-1.65). CONCLUSION Information about prior emergency contraceptive use was not a useful predictor of subsequent pregnancy, infection, or sex at risk for pregnancy among these young women.
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Affiliation(s)
- Petra M Sander
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Raymond EG, L’Engle KL, Tolley EE, Ricciotti N, Arnold MV, Park S. Comprehension of a prototype emergency contraception package label by female adolescents. Contraception 2009; 79:199-205. [DOI: 10.1016/j.contraception.2008.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Revised: 08/25/2008] [Accepted: 09/13/2008] [Indexed: 10/21/2022]
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Abstract
BACKGROUND To explore why increased access to emergency contraception (EC) failed to reduce pregnancies in a recent randomized controlled trial. METHODS We used multivariable logistic regression to identify risk factors for unintended pregnancy using data from a trial involving sexually active women (n = 1490, aged 14-24 years) randomly assigned to either increased access or standard access to EC. We used predictive modeling to generate estimated pregnancy risk scores for each participant. We then examined EC use among women at low or high baseline risk of pregnancy. RESULTS Gravidity, recent history of unprotected sex (within 14 days of enrollment to study) and lower aversion to pregnancy predicted unintended pregnancy. Women in the increased access group were more likely than women in the standard access group to use EC repeatedly. This difference was significantly stronger (P = 0.03) among low risk women than high risk women [Relative risk (RR) 10.0, 95% confidence interval (CI) 6.5-15.4 and RR 5.5, 95% CI 3.8-7.9, respectively]. CONCLUSIONS Increased access to EC had a greater impact on women who were at lower baseline risk of pregnancy. This may explain in part why increased access to EC has had no measurable benefit in clinical trials.
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Affiliation(s)
- Laura Baecher
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, 101 Manning Drive, CB #7570, Chapel Hill, NC 27514, USA.
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Raymond EG, Weaver MA. Effect of an emergency contraceptive pill intervention on pregnancy risk behavior. Contraception 2008; 77:333-6. [DOI: 10.1016/j.contraception.2008.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 01/15/2008] [Accepted: 01/15/2008] [Indexed: 12/30/2022]
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Halpern V, Rountree W, Raymond EG, Law M. The effects of spermicides containing nonoxynol-9 on cervical cytology. Contraception 2008; 77:191-4. [DOI: 10.1016/j.contraception.2007.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 10/29/2007] [Accepted: 11/08/2007] [Indexed: 11/25/2022]
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Raymond EG, Liku J, Schwarz EB. Feasibility of recruitment for an efficacy trial of emergency contraceptive pills. Contraception 2008; 77:118-21. [DOI: 10.1016/j.contraception.2007.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2007] [Revised: 09/19/2007] [Accepted: 09/29/2007] [Indexed: 11/30/2022]
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Raymond EG, Taylor D, Cates W, Tolley EE, Borasky D, Cancel A, Masse B, Bukusi EA, Johnson BR. Pregnancy in effectiveness trials of HIV prevention agents. Sex Transm Dis 2008; 34:1035-9. [PMID: 17621249 DOI: 10.1097/olq.0b013e3180e90586] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Harwood B, Meyn LA, Ballagh SA, Raymond EG, Archer DF, Creinin MD. Cervicovaginal colposcopic lesions associated with 5 nonoxynol-9 vaginal spermicide formulations. Am J Obstet Gynecol 2008; 198:32.e1-7. [PMID: 18166301 DOI: 10.1016/j.ajog.2007.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 01/19/2007] [Accepted: 05/12/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study was undertaken to compare the colposcopic appearance of the cervicovaginal epithelium with spermicide use vs condom use in a low-risk population. STUDY DESIGN This was an ancillary study of a trial comparing the efficacy of 5 nonoxynol-9 spermicides. A cohort of women who used condoms without spermicide served as a control group. Colposcopic examinations were performed during product use to identify genital lesions. RESULTS One hundred fifty-one participants had 1 or more follow-up examinations. At baseline, study groups differed only by the prevalence of baseline lesions. New lesions were identified at 49% of follow-up visits. Controlling for the presence of a baseline lesion, compared with condom use none of the spermicides were associated with an increase in new lesions (overall odds ratio, 0.8; 95% CI, 0.4-1.6; P = .5); and lesions characterized by epithelial disruption were less frequent with spermicide use (overall odds ratio, 0.3; 95% CI, 0.1-0.6; P < .001). CONCLUSION In a low-risk population, women who used nonoxynol-9 spermicides were less likely to have lesions with epithelial disruption, and equally likely to have any new lesion compared with condom use.
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Affiliation(s)
- Bryna Harwood
- Department of Obstetrics and Gynecology, University of Illinois at Chicago College of Medicine, Chicago, IL, USA
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