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Humphries H, Upfold M, Mahlase G, Mdladla M, Gengiah TN, Abdool Karim Q. Implants for HIV prevention in young women: Provider perceptions and lessons learned from contraceptive implant provision. PLoS One 2022; 17:e0262043. [PMID: 35025908 PMCID: PMC8758078 DOI: 10.1371/journal.pone.0262043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/15/2021] [Indexed: 12/05/2022] Open
Abstract
Preventing new HIV infections, especially amongst young women, is key to ending the HIV epidemic especially in sub-Saharan Africa. Potent antiretroviral (ARV) drugs used as pre-exposure prophylaxis (PrEP) are currently being formulated as long-acting implantable devices, or nanosuspension injectables that release drug at a sustained rate providing protection from acquiring HIV. PrEP as implants (PrEP Implants) offers an innovative and novel approach, expanding the HIV prevention toolbox. Feedback from providers and future users in the early clinical product development stages may identify modifiable characteristics which can improve acceptability and uptake of new technologies. Healthcare workers (HCWs) perspectives and lessons learned during the rollout of contraceptive implants will allow us to understand what factors may impact the roll-out of PrEP implants. We conducted eighteen interviews with HCWs (9 Nurses and 9 Community Healthcare Workers) in rural KwaZulu-Natal, South Africa. HCWs listed the long-acting nature of the contraceptive implant as a key benefit, helping to overcome healthcare system barriers like heavy workloads and understaffing. However, challenges like side effects, migration of the implant, stakeholder buy-in and inconsistent training on insertion and removal hampered the roll-out of the contraceptive implant. For PrEP implants, HCWs preferred long-acting products that were palpable and biodegradable. Our findings highlighted that the characteristics of PrEP implants that are perceived to be beneficial by HCWs may not align with that of potential users, potentially impacting the acceptability and uptake of PrEP implants. Further our data highlight the need for sustained and multi-pronged approaches to training HCWs and introducing new health technologies into communities. Finding a balance between the needs of HCWs that accommodate their heavy workloads, limited resources at points of delivery of care and the needs and preferences of potential users need to be carefully considered in the development of PrEP implants.
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Affiliation(s)
- Hilton Humphries
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Michele Upfold
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Gethwana Mahlase
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Makhosazana Mdladla
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Tanuja N. Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Schrager S, Yogendran L, Marquez CM, Sadowski EA. Adenomyosis: Diagnosis and Management. Am Fam Physician 2022; 105:33-38. [PMID: 35029928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Adenomyosis is a clinical condition where endometrial glands are found in the myometrium of the uterus. One in three patients with adenomyosis is asymptomatic, but the rest may present with heavy menstrual bleeding, pelvic pain, or infertility. Heavy menstrual bleeding is the most common symptom. Adenomyosis is distinct from endometriosis (the presence of endometrial glands outside of the uterus), but the two conditions often occur simultaneously. Risk factors for developing adenomyosis include increasing age, parity, and history of uterine procedures. Most patients are diagnosed from 40 to 50 years of age, but younger patients with infertility are increasingly being diagnosed with adenomyosis as imaging modalities improve. Diagnosis of adenomyosis begins with clinical suspicion and is confirmed with transvaginal ultrasonography and pelvic magnetic resonance imaging. Treatment of adenomyosis typically starts with hormonal menstrual suppression. Levonorgestrel-releasing intrauterine systems have shown some effectiveness. Patients with adenomyosis may ultimately have a hysterectomy if symptoms are not controlled with medical therapy.
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Affiliation(s)
- Sarina Schrager
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Lashika Yogendran
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Vanpouille C, Günaydın G, Jangard M, Clerici M, Margolis L, Broliden K, Introini A. The Progestin Medroxyprogesterone Acetate Affects HIV-1 Production in Human Lymphoid Tissue Explants in a Dose-Dependent and Glucocorticoid-like Fashion. Viruses 2021; 13:v13112303. [PMID: 34835109 PMCID: PMC8621851 DOI: 10.3390/v13112303] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/31/2021] [Accepted: 11/12/2021] [Indexed: 11/24/2022] Open
Abstract
The association between the use of the injectable contraceptive depot medroxyprogesterone acetate and HIV-1 susceptibility has been addressed mainly in respect to the changes occurring in the female genital mucosa and blood. However, one of the main sites of HIV-1 pathogenesis is lymphoid organs. To investigate the immunoregulatory effect of medroxyprogesterone acetate (MPA) at this site, human tonsillar tissue explants were infected ex vivo with either a CCR5 (BaL) or CXCR4 (LAI) HIV-1 variant and the release of p24gag and cytokines was measured in culture supernatant. The response to MPA was compared with that elicited by treatment with progesterone (P4) and dexamethasone (DEX), which selectively binds the glucocorticoid receptor, in donor-matched explant cultures. MPA treatment reduced the replication of both tested HIV-1 strains as well as the production of the mediators of inflammation IL-1β, IL-17A and CCL5, but not CCL20, in a similar way to DEX, whereas P4 had no effect on HIV-1 replication. The magnitude of both MPA and DEX-mediated responses was proportional to the length of exposure and/or administered dose. Blockage of the progesterone and glucocorticoid receptors with mifepristone abolished all observed changes in HIV-1 and cytokine production, and was associated with increased IL-22 levels in HIV-infected explants. Our data indicate that elevated doses of MPA may affect the immune responses in lymphoid tissue in a glucocorticoid-like fashion with an immediate impact on local HIV-1 replication.
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Affiliation(s)
- Christophe Vanpouille
- Section on Intercellular Interactions, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA; (C.V.); (L.M.)
| | - Gökçe Günaydın
- Center for Molecular Medicine, Department of Medicine Solna, Division of Infectious Diseases, Karolinska University Hospital, Karolinska Institutet, 171 77 Solna, Sweden; (G.G.); (K.B.)
| | - Mattias Jangard
- Ear, Nose and Throat Unit, Research Laboratory, Sophiahemmet University, 114 86 Stockholm, Sweden;
| | - Mario Clerici
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
- IRCCS Fondazione Don Carlo Gnocchi, 20148 Milan, Italy
| | - Leonid Margolis
- Section on Intercellular Interactions, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA; (C.V.); (L.M.)
| | - Kristina Broliden
- Center for Molecular Medicine, Department of Medicine Solna, Division of Infectious Diseases, Karolinska University Hospital, Karolinska Institutet, 171 77 Solna, Sweden; (G.G.); (K.B.)
| | - Andrea Introini
- Center for Molecular Medicine, Department of Medicine Solna, Division of Infectious Diseases, Karolinska University Hospital, Karolinska Institutet, 171 77 Solna, Sweden; (G.G.); (K.B.)
- Department of Biomedical and Clinical Sciences L. Sacco, University of Milan, 20157 Milan, Italy
- Correspondence: or
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Lazorwitz A, Aquilante CL, Shortt JA, Sheeder J, Teal S, Gignoux CR. Applicability of ancestral genotyping in pharmacogenomic research with hormonal contraception. Clin Transl Sci 2021; 14:1713-1718. [PMID: 33650294 PMCID: PMC8504805 DOI: 10.1111/cts.13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/07/2021] [Accepted: 01/18/2021] [Indexed: 11/29/2022] Open
Abstract
To compare etonogestrel pharmacokinetic and pharmacodynamic outcomes by both self-reported race/ethnicity and genetically determined ancestry among contraceptive implant users. We conducted a secondary analysis of our parent pharmacogenomic study of 350 implant users. We genotyped these reproductive-aged (18-45 years) women for 88 ancestry-informative single nucleotide polymorphisms. We then assigned each participant a proportion value for African (AFR), European (EUR), and Indigenous American (AMR) ancestry based on reference population data. We correlated genetic ancestry with self-reported race/ethnicity and utilized genetic ancestry proportion values as variables for previously performed association analyses with serum etonogestrel concentrations and progestin-related side effects (e.g., bothersome bleeding and subjective weight gain). We successfully estimated genetically determined ancestry for 332 participants. EUR, AFR, and AMR ancestry were each highly correlated with self-reported White/non-Hispanic race (r = 0.64, p = 4.14 × 10-40 ), Black/African American race (r = 0.88, p = 1.36 × 10-107 ), and Hispanic/Latina ethnicity (r = 0.68, p = 4.03 × 10-47 ), respectively. Neither genetically determined ancestry nor self-reported race/ethnicity were significantly associated with serum etonogestrel concentrations. AFR ancestry and self-reported Black race had similar associations with reporting monthly periods (odds ratio [OR] 2.18, p = 0.09 vs. OR 2.22, p = 0.02) and having received treatment for bothersome bleeding (OR 5.19, p = 0.005 vs. OR 4.73, p = 2.0 × 10-4 ). In multivariable logistic regression for subjective weight gain, AMR ancestry dropped out of the model in preference for self-reported Hispanic/Latina ethnicity. We found no new associations between genetically determined ancestry and contraceptive implant pharmacodynamics/pharmacokinetics. Self-reported race/ethnicity were strong surrogates for genetically determined ancestry among this population of contraceptive implant users. Our data suggest that self-reported race/ethnicity, capturing societal and cultural aspects, remain important to the investigation of progestin-related side effects.
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Affiliation(s)
- Aaron Lazorwitz
- Division of Family PlanningDepartment of Obstetrics and GynecologyUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Christina L. Aquilante
- Skaggs School of Pharmacy and Pharmaceutical SciencesDepartment of Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Jonathan A. Shortt
- Colorado Center for Personalized MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Jeanelle Sheeder
- Division of Family PlanningDepartment of Obstetrics and GynecologyUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Stephanie Teal
- Division of Family PlanningDepartment of Obstetrics and GynecologyUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Christopher R. Gignoux
- Colorado Center for Personalized MedicineUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
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Lazorwitz A, Sheeder J, Teal S. An exploratory study on the association of lifestyle factors with serum etonogestrel concentrations among contraceptive implant users. EUR J CONTRACEP REPR 2021; 26:323-325. [PMID: 33596152 PMCID: PMC8496990 DOI: 10.1080/13625187.2021.1887475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/08/2020] [Revised: 01/14/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To explore how diet and exercise habits associate with serum etonogestrel concentrations among contraceptive implant users. MATERIALS AND METHODS We conducted a secondary analysis of healthy, reproductive-age women using etonogestrel implants. This study was registered on ClinicalTrials.gov, NCT03092037. We assessed diet and exercise habits with two validated surveys: Healthy Eating Vital Signs and the Stanford Brief Activity Survey. Participants previously had their serum etonogestrel concentrations measured using a validated liquid-chromatography mass-spectrometry assay. We then used linear modelling to test for associations between survey responses and serum etonogestrel concentrations. RESULTS Among 129 participants, diet and exercise habits had no significant associations with serum etonogestrel concentrations (p = 0.22-0.72), with inconsistent effects found for increased caloric intake and sedentary lifestyle. CONCLUSION This exploratory study found no significant effect of diet or exercise habits on steady-state pharmacokinetics among contraceptive implant users. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov: NCT03092037.
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Affiliation(s)
- Aaron Lazorwitz
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Division of Family Planning, 12631 E 17 Ave, B198-2, Aurora, Colorado, 80045, USA
| | - Jeanelle Sheeder
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Division of Family Planning, 12631 E 17 Ave, B198-2, Aurora, Colorado, 80045, USA
| | - Stephanie Teal
- University of Colorado Anschutz Medical Campus, Department of Obstetrics and Gynecology, Division of Family Planning, 12631 E 17 Ave, B198-2, Aurora, Colorado, 80045, USA
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Zhu L, Yang X, Cao B, Tang S, Tong J. The suture fixation of levonorgestrel-releasing intrauterine device using the hysteroscopic cold-knife surgery system: an original method in treatment of adenomyosis. Fertil Steril 2021; 116:1191-1193. [PMID: 34238576 DOI: 10.1016/j.fertnstert.2021.05.113] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/22/2021] [Accepted: 05/28/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To introduce an effective approach using the hysteroscopic cold-knife surgery system (HCSS) for suture fixation of the levonorgestrel-releasing intrauterine device (LNG-IUD) in patients with adenomyosis. DESIGN Video description of the surgical procedures to demonstrate the detailed technique. The study was reviewed and approved by the institutional review board of Hangzhou Women's Hospital. SETTING Maternity hospital. PATIENT(S) A 39-year-old woman diagnosed with adenomyosis had endured 7 years of severe dysmenorrhea and 4 years of heavy menstrual bleeding. She had a past medical history that was significant for expulsion of an LNG-IUD. Transvaginal ultrasonography revealed that her uterus was enlarged by adenomyosis. She insisted on preserving fertility potential. INTERVENTION(S) We proceeded with the HCSS and the uterine cavity was found enlarged significantly. In consideration of the patient's strong desire for maintaining fertility options, the fixation of the LNG-IUD on the intrauterine posterior wall with an Ethibond suture was performed successfully through an endoscopic needle driver and a knot-pushing device. Proficient endoscopic suturing is the key to the technique. Informed consent was obtained from the patient. MAIN OUTCOME MEASURE(S) Feasibility and value of using the HCSS to fix an LNG-IUD for treatment of adenomyosis. RESULT(S) The LNG-IUD was fixed successfully by the HCSS with an Ethibond suture on the posterior wall of the uterus within 30 minutes, and the intraoperative blood loss was 2 mL. The patient was discharged 24 hours postoperatively without any adverse perioperative complications. At the one-year follow-up, the patient reported obvious relief of her dysmenorrhea and menorrhagia and no more experience with expulsion. Ultrasound demonstrated normal position of the IUD at 1, 3, 6, and 12 months postoperatively. CONCLUSION(S) Hysteroscopy presents a clear visual field to locate and fix the IUD. In patients with adenomyosis suffering from dysmenorrhea or excessive menstrual blood loss, suture fixation of the LNG-IUD using the HCSS can be a minimally invasive and effective alternative for treating adenomyosis, especially in patients who have previously expelled an LNG-IUD, preventing the risk of expulsion.
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Affiliation(s)
- Linling Zhu
- Department of Gynecology, Hangzhou Women's Hospital, Zhejiang, People's Republic of China
| | - Xinyun Yang
- Department of Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Benben Cao
- Department of Gynecology, Hangzhou Women's Hospital, Zhejiang, People's Republic of China
| | - Shanshan Tang
- Department of Gynecology, Hangzhou Women's Hospital, Zhejiang, People's Republic of China
| | - Jinyi Tong
- Department of Gynecology, Hangzhou Women's Hospital, Zhejiang, People's Republic of China.
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Buyuk GN, Oskovi-Kaplan ZA, Kansu-Celik H, Neselioglu S, Erel O, Engin-Ustun Y. Copper and levonorgestrel containing intrauterine devices: comparison of their effect on oxidative stress markers. Gynecol Endocrinol 2021; 37:320-323. [PMID: 33594922 DOI: 10.1080/09513590.2021.1878132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
We aimed to evaluate the oxidative stress by measuring the thiol-disulfide balance in women who use either T380A or LNG-IUD as a contraceptive method. Material and method: The study included two groups; 30 women with LNG-IUD and 30 women with copper-IUD. Thiol-disulfide homeostasis as a marker of oxidative stress was analyzed before the IUD insertion and on the 6th month after insertion. Results: The LNG-IUD group had similar native thiol levels with Cu-IUD (293.1 ± 43.5 µmol/l vs. 290.4 ± 42.4 µmol/l respectively, p = 819). In the copper-IUD group total thiol levels were higher than LNG-IUD group (345.5 ± 58.2 µmol/l vs. 319.5 ± 52.4 µmol/l, p = .031). A significant increase was observed after 6 months in LNG-IUD patients in terms of disulfide/native thiol (7.9 ± 4.4% vs. 11.2 ± 2.6%, p = .006), disulfide/total thiol (6.2 ± 1.8% vs. 8.7 ± 1.9%, p = .004) and Native thiol/total thiol (87.1 ± 12.1% vs. 82.3 ± 8.2%, p = .004) levels. After 6 months in copper-IUD patients, disulfide (22.3 ± 7.3 µmol/l vs. 27.5 ± 6.9 µmol/l respectively, p = .006), disulfide/native thiol (7.7 ± 3.8% vs. 9.8 ± 2.4% respectively, p = .007), disulfide/total thiol (6.4 ± 2.03% vs. 8.2 ± 1.8% respectively, p = .007) and native thiol/total thiol (86.3 ± 9.4% vs. 83.8 ± 10.6% respectively, p = .007) levels were increased. Conclusion: An increase in oxidative stress markers were observed in both groups. Studies evaluating the long term subclinical risks of IUD's are needed to understand the outcomes of the increased oxidative stress.
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Affiliation(s)
- Gul Nihal Buyuk
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Z Asli Oskovi-Kaplan
- Department of Obstetrics and Gynecology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Hatice Kansu-Celik
- Department of Obstetrics and Gynecology, Lokman Hekim Hospital, Ankara, Turkey
| | - Salim Neselioglu
- Department of Clinical Biochemistry, Yildirim Beyazit University, Faculty of Medicine, Ankara, Turkey
| | - Ozcan Erel
- Department of Clinical Biochemistry, Yildirim Beyazit University, Faculty of Medicine, Ankara, Turkey
| | - Yaprak Engin-Ustun
- Department of Obstetrics and Gynecology, Etlik Zübeyde Hanim Women's Health Training and Research Hospital, Ankara, Turkey
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Niu X, Luo Q, Wang C, Zhu L, Huang L. Effects of Etonogestrel implants on pelvic pain and menstrual flow in women suffering from adenomyosis or endometriosis: Results from a prospective, observational study. Medicine (Baltimore) 2021; 100:e24597. [PMID: 33578561 PMCID: PMC7886396 DOI: 10.1097/md.0000000000024597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/13/2021] [Indexed: 01/05/2023] Open
Abstract
Adenomyosis and endometriosis are common causes of pelvic pain in women of reproductive age. Furthermore, adenomyosis is a major cause of menorrhagia. This study aimed to evaluate the effects of Etonogestrel implants on pelvic pain and menstrual flow in women requiring long-acting reversible contraception and suffering from adenomyosis or endometriosis.One hundred women with adenomyosis or endometriosis and asking for contraception with Etonogestrel implants were enrolled in this study and were followed-up for 24 months. Patients were interviewed on pelvic pain by visual analog scale (VAS) pain score, menstrual flow by the number of sanitary napkins, menstrual bleeding pattern, weight gain, breast pain, and any other treatment side effects.Seventy four patients who were treated with Etonogestrel implants completed the 24-month follow-up in which we found a significant decrease in pelvic pain VAS scores comparing baseline scores to 6, 12, and 24 months (baseline: 6.39 ± 2.35 to 24-month: 0.17 ± 0.69, P < 0.05). The menstrual volume decreased significantly compared with that at baseline ((40.69 ± 30.92) %, P < 0.05). However, vaginal bleeding, amenorrhea, weight gain, and acne occurred after treatment in some patients.Etonogestrel implants were effective in reducing pelvic pain and menstrual flow of adenomyosis or endometriosis.
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Affiliation(s)
- Xiaocen Niu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou
| | - Qun Luo
- Zhejiang Province Lin’an District Maternal and Child Health Care Center, PR China
| | - Chunfen Wang
- Zhejiang Province Lin’an District Maternal and Child Health Care Center, PR China
| | - Lihua Zhu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou
| | - Lili Huang
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou
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Twirla - a new contraceptive patch. Med Lett Drugs Ther 2021; 63:17-8. [PMID: 33647003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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Battaglia C, Battaglia B, Casadio P, Rizzo R, Artini PG. Metformin metabolic and vascular effects in normal weight hyperinsulinemic polycystic ovary syndrome patients treated with contraceptive vaginal ring. A pilot study. Gynecol Endocrinol 2020; 36:1062-1069. [PMID: 32544018 DOI: 10.1080/09513590.2020.1770213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The aim of this longitudinal, controlled, and retrospective pilot study was to assess how metformin, associated with a contraceptive vaginal ring, may influence lipid and carbohydrate metabolism, and surrogate markers of arterial function in normal weight polycystic ovary syndrome patients. MATERIAL AND METHODS Among 28 lean patients, 15 were treated with vaginal ring plus metformin and 13 women with only vaginal ring. The effects were assessed after six months. The patients were submitted to evaluation of lipid and carbohydrate metabolism; Doppler analysis of ophthalmic artery; brachial artery flow-mediated vasodilatation; and oral glucose tolerance test. RESULTS After six months, the fasting insulin, glucose/insulin ratio, and homeostatic model assessment estimates for insulin resistance were significantly improved in metformin group. The ophthalmic artery pulsatility index did not significantly improve in either group. The brachial artery vasodilation was better in metformin treated patients. CONCLUSION Metformin, associated with vaginal ring, improves the insulin and carbohydrate metabolism. This, associated with the significant improvements of surrogate markers of arterial function, may be responsible of a slight possible cardiovascular and cerebrovascular protective effect.
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Affiliation(s)
- Cesare Battaglia
- Department of Obstetrics and Perinatal Medicine, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Bruno Battaglia
- Department of Ophthalmology, University of Modena-Reggio-Emilia, Italy
| | - Paolo Casadio
- Department of Gynecology and Pathophysiology of Human Reproduction, Alma Mater Studiorum-University of Bologna, Italy
| | - Roberta Rizzo
- Department of Obstetrics and Perinatal Medicine, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Paolo G Artini
- Department of Obstetrics and Gynecology "P. Fioretti" University of Pisa, Italy
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Grandi G, De Fata R, Varliero F, Del Savio MC, Facchinetti F. Contemporary prescriptions pattern of different dose levonorgestrel-releasing intrauterine systems in an Italian service for family planning. Gynecol Endocrinol 2020; 36:1086-1089. [PMID: 32748655 DOI: 10.1080/09513590.2020.1802420] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Current research informations fail to adequately inform about when levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg is used instead of other lower dose LNG-IUSs (13.5 and 19.5 mg) and other long-acting reversible contraceptives (LARCs) in clinical practice. METHODS A retrospective cohort study was performed in a third-level Service for Family Planning of Modena University hospital about all the first modern contraceptives prescriptions in the whole year 2019 performed by the same group of physicians. All women included underwent a detailed transvaginal ultrasound (TVUS) at prescription and a second evaluation within 3 months when they were still using the prescribed method. RESULTS To 69/160 (43.1%) women a short-acting reversible contraceptive (SARC), while to 91/160 (56.9%) a LARC was prescribed. Women with a LARC prescription were older than them with a short-acting (SARC) (p < .0001). Women with LNG-IUS 52 mg prescription were significantly the oldest (42.9 ± 5.3), while those with intrauterine copper device and lower dose LNG-IUS were of similar age (36.5 ± 7.3 and 34.9 ± 2.3), significantly lower (p < .005). Women with implant prescription had the same age as SARC, being the youngest (30.7 ± 8.9 and 31.0 ± 9.5) (p < .0001). Women with LNG-IUS 52 mg prescription mg presented with bigger uterine volume (p = .001). In multivariate analyses, the LNG-IUS 52 mg prescription was significantly linked only to age (OR 1.24; 95% CI 1.11-1.37, p < .0001) and presence of adenomyosis (OR 4.56; 95% CI 1.45-14.33, p = .009). CONCLUSIONS The use of LNG-IUS 52 mg instead of other LARCs is preferred for older women, with uteri of increased volume due to adenomyosis, suggesting a possible differential use of available LNG-IUSs in the contemporary clinical practice.
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Affiliation(s)
- Giovanni Grandi
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Riccardo De Fata
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Federico Varliero
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Maria Chiara Del Savio
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Fabio Facchinetti
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
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Hernandez AMC, Dietrich JE. Gynecologic Management of Pediatric and Adolescent Patients with Ehlers-Danlos Syndrome. J Pediatr Adolesc Gynecol 2020; 33:291-295. [PMID: 31883462 DOI: 10.1016/j.jpag.2019.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 12/07/2019] [Accepted: 12/19/2019] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Ehlers-Danlos syndrome (EDS) is a connective tissue disorder resulting in abnormal collagen synthesis leading to skin, joint, ligament, blood vessel, and organ abnormalities. Studies in adult women show an association with heavy menstrual bleeding, dysmenorrhea, and pelvic organ prolapse. We aimed to evaluate gynecologic complaints in pediatric and adolescent patients with EDS and their management by pediatric and adolescent gynecology (PAG) Providers. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Charts of female individuals less than 21 years of age with an International Classification of Diseases (ICD) Ninth or Tenth revision diagnosis of EDS who were evaluated between July 1, 2007, and July 31, 2017, were reviewed for menstrual history, gynecologic complaints, and interventions prescribed. RESULTS A total of 156 patients met inclusion criteria, and 26 (16.7%) were seen by PAG providers. The mean age was 14.5 ± 1.9 years. Fifteen (57.7%) reported dysmenorrhea, 13 (50%) complained of heavy menstrual bleeding (HMB), 10 (38.5%) reported irregular menses, and 7 (26.9%) sought contraception. Concurrent medical problems were reviewed, as this affected hormone choice. The cohort was stratified into 2 groups: patients whose menstrual cycles were well controlled on a single method (group A), and patients who tried multiple medications (group B). Progesterone-only pills were most commonly used in froup A. Eleven (73%) patients in group B tried depot medroxyprogesterone acetate (DMPA), but ultimately a levonorgestrel intrauterine device (IUD) was the most popular final choice of treatment and was used by 4 (27%) patients. CONCLUSION Few adolescents with EDS are referred to PAG providers despite the prevalence of gynecologic complaints and potential for obstetric and gynecologic complications. In this population, early entry to gynecologic care would be beneficial.
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Affiliation(s)
- Angela Marie C Hernandez
- Department of Obstetrics and Gynecology, University of California San Francisco-Fresno, Fresno, California.
| | - Jennifer E Dietrich
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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Abstract
This study aimed to investigate the efficacy of the etonogestrel (ENG)-releasing implant in treating patients with rectovaginal endometriosis. The study was based on the retrospective analysis of a prospectively collected database, including symptomatic women who had ultrasonographic diagnosis of rectovaginal endometriosis. Patients were follow-up at 6, 12 and 24 months from the insertion of the ENG-releasing implant. The intensity of pain symptoms was evaluated using a visual analog scale. The volume of the nodules was estimated by virtual organ computer-aided analysis. The Endometriosis Health Profile (EHP-30) was used to evaluate quality of life. Overall, 43 women were included in the study. The 2-year continuation rate for the ENG-releasing implant was 93.0%. The treatment quickly improved the intensity of non-menstrual pelvic pain, deep dyspareunia, dysmenorrhea, and dyschezia. At 6-month follow-up, there were improvements in all domains of the EHP-30 compared with baseline. Further improvements in the EHP-30 results were observed only in pain sub score at 12-month follow-up and in emotional well-being sub score at 24-month follow-up. At 6-month follow-up the volume of the rectovaginal nodules was significantly lower compared with baseline; a further decrease was observed at 12- and 24-month follow-up. The treatment was well tolerated.
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Affiliation(s)
- Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
- Piazza Della Vittoria 14 Srl, Genova, Italy
| | - Carolina Scala
- Unit of Obstetrics and Gynecology, Gaslini Institute, Genova, Italy
| | | | - Valerio Gaetano Vellone
- Department of Surgical and Diagnostic Sciences (DISC), Ospedale Policlinico San Martino, Genova, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genova, Italy
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Abstract
INTRODUCTION Glanzmann's Thrombasthenia (GT) is a rare autosomal recessive bleeding disorder due to defective platelet membrane glycoprotein GP IIb/IIIa (integrin αIIbβ3). The prevalence is estimated at 1:1,000,000 and it is commonly seen in areas where consanguinity is high. CASE PRESENTATION The authors report a 12 year old Nigerian girl of Igbo ethnic group, born of non-consanguineous parents, who presented with prolonged heavy menstrual bleeding which started at menarche 3 months earlier, weakness and dizziness. She had a past history of recurrent episodes of prolonged epistaxis, gastrointestinal bleeding and gum bleeding during early childhood. On examination, she was severely pale with a haemic murmur and vaginal bleeding. The initial diagnosis was menorrhagia secondary to bleeding diathesis possibly von Willebrand's Disease. She was on supportive treatment with fresh whole blood, fresh frozen plasma and platelets until diagnosis of GT was made in the USA. Currently, she is on 3 monthly intramuscular Depo-provera with remarkable improvement. CONCLUSION To the best of our knowledge, this is the first documented report of GT in our environment where consanguinity is rarely practised. Our health facilities require adequate diagnostic and treatment facilities for rare diseases like GT.
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Affiliation(s)
- Osita U Ezenwosu
- Department of Paediatrics, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
| | - Barth F Chukwu
- Department of Paediatrics, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
| | - Ndubuisi A Uwaezuoke
- Department of Paediatrics, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
| | - Ifeyinwa L Ezenwosu
- Department of Community Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Anthony N Ikefuna
- Department of Paediatrics, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
| | - Ifeoma J Emodi
- Department of Paediatrics, College of Medicine, University of Nigeria, Enugu Campus, Nigeria
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Song SY, Lee SY, Kim HY, Park DB, Kim DE, Lee KH, Lee S, Yang JB, Yoo HJ. Long-term efficacy and feasibility of levonorgestrel-releasing intrauterine device use in patients with adenomyosis. Medicine (Baltimore) 2020; 99:e20421. [PMID: 32481439 DOI: 10.1097/md.0000000000020421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To evaluate the efficacy and feasibility of levonorgestrel-releasing intrauterine device (LNG-IUD) use longer than 5 years in women with adenomyosis.Data were retrospectively collected from patients who were treated with LNG-IUD longer than 5 years at the Chungnam National University hospital for adenomyosis diagnosed with ultrasonography from January 2006 to November 2013.A total of 131 patients who were diagnosed with adenomyosis had treated with LNG-IUD longer than 5 years. The mean duration of keeping 1 device without replacement was 58.35 ± 15.98 months, and total duration of LNG-IUD treatment was 83.86 ± 23.88 months. A total of 51 patients stopped using LNG-IUD after 5 years and the mean age at the time of LNG-IUD removal was 52.46 ± 6.9. LNG-IUD treatment had a significant effect on both menorrhagia and dysmenorrhea starting from the first month of insertion (P < .01), which persisted until 6 years when the effect started to plateau. The decrease in uterine volume was not consistent during the treatment period. The uterine volume decreased significantly only in the first and second year of LNG-IUD treatment and then from eighth to tenth year of LNG-IUD treatment (P < .05). Adverse events after insertion of LNG-IUD decreased significantly after 5 years.LNG-IUD treatment longer than 5 years is an effective and feasible method for patients diagnosed with adenomyosis.
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Affiliation(s)
| | - Sun Yeul Lee
- Department of Anesthesiology and Pain Medicine, Chungnam National University School of Medicine
| | | | | | | | | | - Siyeo Lee
- Department of Biochemistry, College of Natural Sciences, Chungnam National University, Daejeon, Republic of Korea
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OJO O, NDIKOM C, ALABI P. Predictors of the usage of contraceptive implants among women of reproductive age in Ondo State, Southwest Nigeria. J Prev Med Hyg 2020; 61:E39-E47. [PMID: 32490268 PMCID: PMC7225643 DOI: 10.15167/2421-4248/jpmh2020.61.1.1367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/18/2020] [Indexed: 11/16/2022]
Abstract
Background A major characteristic of all developing countries is rapid population growth which is due to high fertility, birth rates and poor utilization of contraceptive methods. This study therefore assessed the predictors of contraceptive implants utilization among women of reproductive age in Ondo State, Nigeria. Methods A descriptive cross-sectional study design was used and a total of 230 women were selected by multi-stage sampling technique. Questionnaire administration was interviewer-based majority of the women could not read. Data analysis was conducted using SPSS version 23. Research questions and hypotheses were answered and tested with descriptive statistics (frequency, percentages), chi-square test of significance and binary logistic regression. Levels of significance was set at p ≤ 0.05. Results The prevalence of contraceptive utilization (any method) and contraceptive implant utilization were 92.2% and 31.1% respectively. Variables such as education (χ2 = 6.91, p = 0.03) and lack of counseling from providers (χ2 = 5.05, p = 0.03) were significantly associated with the utilization of contraceptive implant. These two variables were also the predictors of contraceptive implant utilization. Women with secondary and tertiary education have higher odds of utilizing contraceptive implants (OR = 1.21, 95% CI = 1.01-7.82, p = 0.04) and (OR = 2.53, 95% CI = 1.49-11.47, p = 0.03) compared to women who had primary or no education while those who claimed to be adequately counseled by providers are about two times more likely to use contraceptive implants (OR = 2.33, 95% CI = 1.08-5.51) Conclusion This study showed the important role of education and health workers in providing information about contraceptive implants. Therefore, health workers’ knowledge of family planning counseling and services should be constantly upgraded so as to improve their roles in educating, mobilizing, counseling the women regarding contraceptive implant insertion.
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Affiliation(s)
- O.O. OJO
- Faculty of Nursing Science, University of Medical Sciences Akure Campus, Nigeria
- Department of Nursing, University of Ibadan, Nigeria
- Correspondence: Olufisayo Olusola Ojo, Department of Nursing, Faculty of Nursing Science, University of Medical Sciences Akure Campus, Nigeria - Tel. +2348034387290 - E-mail:
| | - C.M. NDIKOM
- Department of Nursing, University of Ibadan, Nigeria
| | - P.I. ALABI
- Medicins Sans Frontieres, Spain, Nigeria Mission, Damaturu Project
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17
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Castaño PM, Westhoff CL. Experience with same-day placement of the 52 mg levonorgestrel-releasing intrauterine system. Am J Obstet Gynecol 2020; 222:S883.e1-S883.e6. [PMID: 31945336 DOI: 10.1016/j.ajog.2019.12.268] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/30/2019] [Accepted: 12/30/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prescribing information for the levonorgestrel-releasing intrauterine system allows placement when the clinician is reasonably certain the patient is not pregnant. A 6 item checklist aids clinicians in determining pregnancy risk but may be too restrictive, resulting in delaying placement for many women. Same-day placement, however, may risk placement during an unrecognized luteal-phase pregnancy, that is, a preimplantation fertilized ovum not yet detectable by urine pregnancy test. OBJECTIVE We assessed the applicability of pregnancy checklist criteria in 2 gynecology practices that routinely provide same-day placements following a negative urine pregnancy test. STUDY DESIGN In this retrospective cohort study, we reviewed electronic medical records of all women who underwent levonorgestrel-releasing intrauterine system placement from July 2009 to August 2012. We evaluated each record to identify whether the woman met any of the checklist criteria to exclude pregnancy. We ascertained luteal-phase pregnancies and other outcomes within 12 months following placement. RESULTS Of 885 placements, 293 (33%) were immediately after abortion. Of the remaining 592 placements, 353 (60%) met at least 1 pregnancy checklist criterion to rule out pregnancy but 239 (40%) met none. Two percent received levonorgestrel emergency contraception at the time of placement. One luteal-phase pregnancy occurred in the group not meeting pregnancy checklist criteria. Removals and expulsions were rare and similar whether or not patients met checklist criteria. CONCLUSION In 2 practices that provide same-day intrauterine system placements, strict adherence to pregnancy checklist criteria would have resulted in 239 patients (40%) not receiving a same-day intrauterine system. Twelve month outcomes were similar whether or not patients met pregnancy checklist criteria. Providers need not withhold intrauterine system placement based on the pregnancy checklist criteria.
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Affiliation(s)
- Paula M Castaño
- Division of Family Planning, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY.
| | - Carolyn L Westhoff
- Division of Family Planning, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center and New York-Presbyterian Hospital, New York, NY
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18
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Gawron LM, Gero A, Kushner KL, Turok DK, Sanders JN. Unprotected intercourse in the 2 weeks prior to quick-start initiation of an etonogestrel contraceptive implant with and without use of oral emergency contraception. Am J Obstet Gynecol 2020; 222:S891-S892. [PMID: 31809707 PMCID: PMC7219276 DOI: 10.1016/j.ajog.2019.11.1281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/07/2019] [Accepted: 11/05/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Lori M Gawron
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132.
| | - Alexandra Gero
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132
| | | | - David K Turok
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132
| | - Jessica N Sanders
- University of Utah, 30N 1900E, Room 2B-200, Salt Lake City, UT 84132
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Dinehart E, Lathi RB, Aghajanova L. Levonorgestrel IUD: is there a long-lasting effect on return to fertility? J Assist Reprod Genet 2020; 37:45-52. [PMID: 31709489 PMCID: PMC7000571 DOI: 10.1007/s10815-019-01624-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 07/24/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022] Open
Abstract
Intrauterine devices (IUDs) are effective and safe long-acting reversible contraceptive methods for preventing unplanned pregnancies. While extensive studies were conducted to evaluate return to fertility after removal of IUDs, majority of them were focused on multiparous women using copper IUDs. Current trends indicate increased use of levonorgestrel (LNG) IUDs in nulliparous women for very long periods of time, with both nulliparity and long duration of LNG-IUD use being potentially associated with trends towards longer time to conception post removal. Understanding the effects that LNG-IUDs may have on endometrial morphology and gene expression has important implications to further understanding their mechanism of action. Studies examining endometrial gene expression show persistent changes in receptivity markers up to 1 year after removal of an inert IUD, and no similar studies have been performed after removal of LNG-IUDs. Given the current gap in the literature and trends in LNG-IUD use in nulliparous young women, studies are needed that specifically look at the interaction of nulliparity, long-term use of LNG-IUD, and return to normal fertility. Herein, we review the available literature on the mechanism of action of IUDs with a specific focus on the effect on endometrial gene expression profile changes associated with IUDs.
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Affiliation(s)
- Erin Dinehart
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC, USA
| | - Ruth B Lathi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA
| | - Lusine Aghajanova
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.
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Abstract
INTRODUCTION Nexplanon is a 4 cm rod-shaped barium sulphate coated contraceptive implant with a usual subdermal insertion in the inner non-dominant upper arm. Complications proper to subdermal contraceptive implants are unusual and principally localized and minor, comprising infection at the site of implantation, hematoma, abnormal scar development, or local nerve and blood vessel injuries. Infrequently, contraceptive implant migration can happen, though habitually not far from the site of insertion. Pulmonary embolization of the device is remarkably rare and can present with symptoms such as chest pain or dyspnea. PATIENT CONCERNS AND DIAGNOSIS We report one of the rare cases of asymptomatic Nexplanon pulmonary embolism in a 26-year-old female. INTERVENTIONS AND OUTCOMES An endovascular intervention successfully retrieved the device from the lateral segment right middle lobe pulmonary artery without any complications. CONCLUSION Several cases of contraceptive implant migration into the pulmonary artery have been reported to this day. Preventing this life-threatening complication is challenging, and yet, no clear guidelines have been established.
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Affiliation(s)
- Joya-Rita Hindy
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Tarek Souaid
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | | | - Joanne Glanville
- Department of General Surgery at Johnston-Willis Hospital, Richmond, VA, USA
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Bao Q, Zou Y, Wang Y, Kozak D, Choi S, Burgess DJ. Drug release testing of long-acting intrauterine systems. J Control Release 2019; 316:349-358. [PMID: 31733294 DOI: 10.1016/j.jconrel.2019.11.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 09/18/2019] [Revised: 11/02/2019] [Accepted: 11/13/2019] [Indexed: 02/01/2023]
Abstract
Performance evaluation of polydimethylsiloxane (PDMS) based long-acting (e.g. 3-5 years) levonorgestrel (LNG) intrauterine systems (IUSs), such as Mirena®, is challenging due to their complex formulation, locally-acting feature, and extremely long duration of drug release. To achieve such long-term release, a large amount of drug (up to 52 mg in Mirena®) must be incorporated as a drug reservoir in the IUS. Consequently, dose dumping or unanticipated changes in the LNG-IUS in vivo release characteristics may give rise to adverse product safety and efficacy. Therefore, it is crucial to understand, and have appropriate control over, the physicochemical properties and in vitro release characteristics of these products. This requires an understanding of the LNG-IUSs drug release mechanism and the development of a sensitive yet robust in vitro release testing method. There have been no previous reports on in vitro drug release and the release mechanism from LNG-IUSs. This is probably a consequence of the extremely slow drug release rate of LNG-IUSs under real-time in-use conditions (e.g., 3-5 years) and therefore it is impractical to obtain complete release profiles (e.g. there is only 60% release in 5 years for Mirena®). Therefore, the development of appropriate accelerated in vitro release methods is imperative. Following preparation of LNG-IUSs, similar to Mirena®, real-time release was tested in (0.9% w/v NaCl) media in a water shaker bath at 37 °C for over 2 years. Addition of surfactant (sodium dodecyl sulfate (SDS)), elevation of temperature, addition of organic solvents (ethanol (EtOH), isopropanol (IPA), tert-butanol (TBA) and tetrahydrofuran (THF)) and a combination thereof were utilized as release media to accelerate drug release for LNG-IUSs. Complete drug release was achieved in 32 and 672 days in THF and TBA hydro-organic media, respectively. The release profile in THF was considered too fast as it may result in change of release mechanism, whereas the release profile in TBA was deemed suitable following model fitting. Model fitting was performed to understand the release characteristics as well as the release mechanisms. The release rate in the hydro-alcoholic media was linearly proportional to the swelling ratio of the PDMS in the corresponding organic solvents. Zero-order, first-order and two-phase models were utilized to fit the release profiles obtained under the different release conditions. The data analysis was comparable using the parameters from different models given the high R2 values. However, the two-phase model was better in terms of the release mechanism of the LNG-IUSs considering the full drug release profile. The present study will facilitate the process of granting of biowaivers through an in vitro approach, thus reducing the necessity for clinical studies. In addition, it will help reduce the regulatory burden without sacrificing product quality of LNG-IUS products.
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Affiliation(s)
- Quanying Bao
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, United States of America
| | - Yuan Zou
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, United States of America
| | - Yan Wang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, United States of America
| | - Darby Kozak
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, United States of America
| | - Stephanie Choi
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, FDA, Silver Spring, MD 20993, United States of America
| | - Diane J Burgess
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, United States of America.
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Callahan RL, Brunie A, Mackenzie ACL, Wayack-Pambè M, Guiella G, Kibira SPS, Makumbi F. Potential user interest in new long-acting contraceptives: Results from a mixed methods study in Burkina Faso and Uganda. PLoS One 2019; 14:e0217333. [PMID: 31136612 PMCID: PMC6538161 DOI: 10.1371/journal.pone.0217333] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 05/09/2019] [Indexed: 11/20/2022] Open
Abstract
Method-related concerns represent an important cause of contraceptive non-use and discontinuation. User preferences must be incorporated into the design of new contraceptive technologies to ensure product success and improve family planning outcomes. We assessed preferences among potential users in Burkina Faso and Uganda for six contraceptive methods currently under development or ready for introduction: a new copper intra-uterine device (IUD), a levonorgestrel intra-uterine system, a new single-rod implant, a biodegradable implant, a longer-acting injectable, and a method of non-surgical permanent contraception. Questions were added to nationally-representative PMA2020 household surveys that asked 2,743 and 2,403 women in Burkina Faso and Uganda, respectively, their interest in using each new method. We assessed factors associated with interest through multivariable logistic regression models. We conducted qualitative interviews and focus groups with 398 women, 78 men, and 52 family planning providers and key informants to explore perceived advantages and disadvantages of the methods. Respondents expressed interest in using all new methods, with greatest interest in the longer-acting injectable (77% in Burkina Faso, 61% in Uganda), followed by a new single-rod implant. Least interest was expressed in a new copper IUD (26% Burkina Faso, 15% in Uganda). In both countries, women with less education had higher odds of interest in a longer-acting injectable. Interest in most new methods was associated with desiring a method lasting longer than one year and acceptance of lack of menstrual bleeding as a contraceptive side effect. Perceived advantages and disadvantages were similar between countries, including concerns about menstrual side effects and fear of the biodegradable nature of the biodegradable implant. Potential users, their partners, and providers are interested in new longer-acting methods, however, familiar forms including the injectable and implant may be the most immediately acceptable. A biodegradable implant will require clear counseling messages to allay potential fears.
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Affiliation(s)
| | - Aurélie Brunie
- Health Services Research, Washington DC, United States of America
| | | | - Madeleine Wayack-Pambè
- Institut Supérieur des Sciences de la Population, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population, Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Simon P. S. Kibira
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Fredrick Makumbi
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Thurman AR, Schwartz JL, Ravel J, Gajer P, Marzinke MA, Yousefieh N, Anderson SM, Doncel GF. Vaginal microbiota and mucosal pharmacokinetics of tenofovir in healthy women using tenofovir and tenofovir/levonorgestrel vaginal rings. PLoS One 2019; 14:e0217229. [PMID: 31107913 PMCID: PMC6527208 DOI: 10.1371/journal.pone.0217229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/05/2019] [Indexed: 12/25/2022] Open
Abstract
Recent data support that the vaginal microbiota may alter mucosal pharmacokinetics (PK) of topically delivered microbicides. Our team developed an intravaginal ring (IVR) that delivers tenofovir (TFV) (8–10 mg/day) alone or with levonorgestrel (LNG) (20 ug/day). We evaluated the effect of IVRs on the vaginal microbiota, and describe how the vaginal microbiota impacts mucosal PK of TFV. CONRAD A13-128 was a randomized, placebo controlled phase I study. We randomized 51 women to TFV, TFV/LNG or placebo IVR. We assessed the vaginal microbiota by sequencing the V3-V4 regions of 16S rRNA genes prior to IVR insertion and after approximately 15 days of use. We measured the concentration of TFV in the cervicovaginal (CV) aspirate, and TFV and TFV-diphosphate (TFV-DP) in vaginal tissue at the end of IVR use. The change in relative or absolute abundance of vaginal bacterial phylotypes was similar among active and placebo IVR users (all q values >0.13). TFV concentrations in CV aspirate and vaginal tissue, and TFV-DP concentrations in vaginal tissue were not significantly different among users with community state type (CST) 4 versus those with Lactobacillus dominated microbiota (all p values >0.07). The proportions of participants with CV aspirate concentrations of TFV >200,000 ng/mL and those with tissue TFV-DP concentrations >1,000 fmol/mg were similar among women with anaerobe versus Lactobacillus dominated microbiota (p = 0.43, 0.95 respectively). There were no significant correlations between the CV aspirate concentration of TFV and the relative abundances of Gardnerella vaginalis or Prevotella species. Tissue concentrations of TFV-DP did not correlate with any the relative abundances of any species, including Gardnerella vaginalis. In conclusion, active IVRs did not differ from the placebo IVR on the effect on the vaginal microbiota. Local TFV and TFV-DP concentrations were high and similar among IVR users with Lactobacillus dominated microbiota versus CST IV vaginal microbiota. Trial registration: ClinicalTrials.gov NCT02235662.
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Affiliation(s)
- Andrea Ries Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
- * E-mail:
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Arlington, VA, United States of America
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Pawel Gajer
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Clinical Pharmacology Analytical Laboratory, Baltimore, MD, United States of America
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Sharon M. Anderson
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Arlington, VA, United States of America
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Ermias Y, Morgan IA, Curtis KM, Whiteman MK, Horton LG, Zapata LB. Factors associated with provision of depot medroxyprogesterone acetate to adolescents by US health care providers. Contraception 2019; 99:300-305. [PMID: 30763582 PMCID: PMC10966425 DOI: 10.1016/j.contraception.2019.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 10/02/2018] [Revised: 12/18/2018] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Identify factors associated with healthcare providers' frequency of depot medroxyprogesterone acetate (DMPA) provision to adolescents. STUDY DESIGN We analyzed data from surveys mailed to a nationally representative sample of public-sector providers and office-based physicians (n=1984). We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with frequent DMPA provision to adolescents in the past year. RESULTS Although most providers (>95%) considered DMPA safe for adolescents, fewer reported frequent provision (89% of public-sector providers; 64% of office-based physicians). Among public-sector providers, factors associated with lower odds of frequent provision included working in settings without Title X funding (aOR 0.44, 95% CI 0.30-0.64), reporting primary care as their primary clinical focus versus reproductive or adolescent health (aOR 0.42, 95% CI 0.28-0.61), and providing fewer patients with family planning services. Among office-based physicians, factors associated with lower odds of frequent provision included specializing in obstetrics/gynecology (aOR 0.50, 95% CI 0.27-0.91) and family medicine (aOR 0.21, 95% CI 0.09-0.47) versus adolescent medicine, completing training ≥15 versus <5 years ago (aOR 0.27, 95% CI 0.09-0.83), and reporting that 0-24% of patients pay with Medicaid or other government healthcare assistance versus ≥50% (aOR 0.23, 95% CI 0.09-0.61). The reason most commonly reported by providers for infrequent DMPA provision was patient preference for another method. CONCLUSIONS While most providers reported frequently providing DMPA to adolescents, training on evidence-based recommendations for contraception, focused on subgroups of providers with lower odds of frequent DMPA provision, may increase adolescents' access to contraception. IMPLICATIONS Although >95% of providers considered depot medroxyprogesterone (DMPA) a safe contraceptive for adolescents, only 89% of public-sector providers and 64% of office-based physicians reported frequently providing DMPA to adolescents. Provider training on evidence-based recommendations for contraception counseling and provision may increase adolescents' access to DMPA and all methods of contraception.
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Affiliation(s)
- Y Ermias
- Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, United States, 30341; Association of Schools and Programs of Public Health (Fellow), 1900 M Street NW, Suite 710, Washington, DC, United States, 20036.
| | - I A Morgan
- Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, United States, 30341; Association of Schools and Programs of Public Health (Fellow), 1900 M Street NW, Suite 710, Washington, DC, United States, 20036.
| | - K M Curtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, United States, 30341.
| | - M K Whiteman
- Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, United States, 30341.
| | - L G Horton
- Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, United States, 30341; Association of Schools and Programs of Public Health (Fellow), 1900 M Street NW, Suite 710, Washington, DC, United States, 20036.
| | - L B Zapata
- Division of Reproductive Health, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA, United States, 30341.
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Abstract
OBJECTIVE Levonorgestrel (LNG) emergency contraception (EC) may have decreased efficacy for women with body mass indices (BMI)≥26kg/m2. This study aims to evaluate the prevalence of LNG EC use and EC counseling among overweight women. METHODS The 2013-2015 dataset from the National Survey of Family Growth was analyzed to determine the proportion of women with BMI≥26kg/m2 who report recent use of LNG EC and EC counseling. RESULTS Overall, 2.4% of respondents reported recent use of LNG EC. Among women using oral LNG for EC, 29.8% of survey participants reported BMI≥26kg/m2. Additionally, 40.2% of women with BMI≥26kg/m2 using oral LNG EC reported having a doctor or medical provider talk to them about emergency contraception within the last 12 months, compared to 18.3% of LNG EC users with BMI<26kg/m2 (p<0.001). CONCLUSIONS Despite recent counseling from clinicians and concerns for decreased efficacy, a significant number of overweight women continue to use LNG for EC. Clinicians should counsel women with BMI≥26kg/m2 on the potential limitations of oral LNG for EC and offer more effective EC methods, including the copper intrauterine device and oral ulipristal acetate.
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Affiliation(s)
- Paris Stowers
- State University of New York Upstate Medical University, Department of Obstetrics and Gynecology, Syracuse, NY, USA.
| | - Renee Mestad
- State University of New York Upstate Medical University, Department of Obstetrics and Gynecology, Syracuse, NY, USA.
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Morgan IA, Ermias Y, Zapata LB, Curtis KM, Whiteman MK. Health Care Provider Attitudes and Practices Related to 'Quick Start' Provision of Combined Hormonal Contraception and Depot Medroxyprogesterone Acetate to Adolescents. J Adolesc Health 2019; 64:211-218. [PMID: 30392865 PMCID: PMC10985629 DOI: 10.1016/j.jadohealth.2018.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 08/14/2018] [Accepted: 08/14/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Adolescents may encounter many barriers to initiating contraception. 'Quick Start' is a recommended approach for initiating contraception on the same day as a provider visit. We examined factors associated with health care provider attitudes and practices related to 'Quick Start' provision of combined hormonal contraception (CHC) and depot medroxyprogesterone acetate (DMPA) to adolescents. METHODS We analyzed weighted survey data from providers in publicly funded health centers and from office-based physicians (n = 2,056). Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the associations between provider characteristics and frequent (very often or often vs. not often or never) 'Quick Start' provision of CHC and DMPA to adolescents in the past year. RESULTS The prevalence of considering 'Quick Start' as safe was high for CHC (public-sector providers [87.5%]; office-based physicians [80.2%]) and DMPA (public-sector providers [80.9%]; office-based physicians [78.8%]). However, the prevalence of frequent 'Quick Start' provision was lower, particularly among office-based physicians (CHC: public-sector providers [74.2%]; office-based physicians [45.2%]; DMPA: public-sector providers [71.4%]; office-based physicians [46.9%]). Providers who considered 'Quick Start' unsafe or were uncertain about its safety had lower odds of frequent 'Quick Start' provision compared with those who considered it safe (public-sector providers: CHC aOR = 0.09 95% CI 0.06-0.13, DMPA aOR = 0.07 95% CI 0.05-0.10; office-based physicians: CHC aOR = 0.06 95% CI 0.02-0.22, DMPA aOR = 0.07 95% CI 0.02-0.20). CONCLUSIONS While most providers reported that 'Quick Start' initiation of CHC and DMPA among adolescents is safe, fewer providers reported frequent 'Quick Start' provision in this population, particularly among office-based physicians.
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Affiliation(s)
- Isabel A Morgan
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia.
| | - Yokabed Ermias
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Lauren B Zapata
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Kathryn M Curtis
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
| | - Maura K Whiteman
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, Georgia
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Wirsing N, Pierce C, Nashelsky J. Can unintended pregnancies be reduced by dispensing a year's worth of hormonal contraception? J Fam Pract 2019; 68:E15-E16. [PMID: 31381631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Nellie Wirsing
- Cascades East Family Medicine Residency, Oregon Health and Science University, Portland, USA
| | - Carrie Pierce
- Cascades East Family Medicine Residency, Oregon Health and Science University, Portland, USA
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