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Contraception Journal
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Contraception Highlights April 2012

This month’s featured editorials

Building trust for shared services: a model for collaboration between nonprofit reproductive health organizations
Clare Coleman, Jodi Magee, Wayne Shields
pages 335-337
A challenging economy, uncertain political support and evolving health technologies call for innovation, collaboration and fresh thinking for all members of the reproductive health community. Clinical practices in the United States are responding to these challenges by testing and implementing shared support services and information systems, driven by the economic downturn, emergence of electronic medical records, and impending health care laws. read more >

The copper IUD for emergency contraception, a neglected option
Peter Belden, Cynthia C. Harper, J. Joseph Speidel
pages 338-339
It can be argued that the most important failing of modern family planning is the persistent epidemic of unintended pregnancy. In developing countries, about 75 million pregnancies annually are unintended, a number close to the 80 million growth of world population each year. In the United States, about half of pregnancies are unintended. By the age of 45 years, about half of women in the United States will have experienced an unintended pregnancy, and one third will have had an abortion. The fact that 47% of the 1.2 million annual abortions in the United States are repeat procedures is additional evidence of ineffective or nonuse of contraception. read more >

Commentary

Plan B, One Step not taken: politics trumps science yet again
Kelly Cleland , Jeffrey F. Peipert, Carolyn Westhoff, Scott Spear, James Trussell
pages 235-239
In a stunning move on December 7, Secretary of Health and Human Services Kathleen Sebelius overruled the Food and Drug Administration's judgment that the levonorgestrel-containing emergency contraceptive pill (ECP) Plan B One-Step should be approved for full nonprescription status without an age restriction. FDA Commissioner Margaret Hamburg announced on the same day that the Center for Drug Evaluation and Research (CDER) had closely reviewed the evidence that Plan B One-Step is safe and effective for women of all ages, including data demonstrating that younger adolescents are sufficiently able to understand how to use the product safely without consulting a health care provider. However, in a maneuver unprecedented in the history of the FDA, Secretary Sebelius unilaterally superseded the authority of the Commissioner and ordered that the agency deny the application.
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Original research articles

Oral contraceptive formulation and risk of breast cancer
Polly A. Marchbanks , Kathryn M. Curtis, Michele G. Mandel, Hoyt G. Wilson, Gary Jeng, Suzanne G. Folger, Jill A. McDonald, Janet R. Daling, Leslie Bernstein, Kathleen E. Malone, Phyllis A. Wingo, Michael S. Simon, Sandra A. Norman, Brian L. Strom, Giske Ursin, Linda K. Weiss, Ronald T. Burkman, Robert Spirtas
pages 342-350
Background: While evidence on the association between oral contraceptive (OC) use and breast cancer generally suggests little or no increased risk, the question of whether breast cancer risk varies by OC formulation remains controversial. Few studies have examined this issue because large samples and extensive OC histories are required.
Conclusions: These results add to the small body of literature on the relationship between OC formulation and breast cancer. Our data are reassuring in that, among women 35–64 years of age, we found no evidence that specific OC formulations increase breast cancer risk.
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A randomized controlled trial of subantimicrobial-dose doxycycline to prevent unscheduled bleeding with continuous oral contraceptive pill use
Bliss Kaneshiro, Alison Edelman, Nichole E. Carlson, Mark Nichols, Marci Messerle Forbes, Jeffrey Jensen
pages 351-358
Background: Unscheduled bleeding is the main side effect of continuous oral contraceptive pills (OCPs) and has been correlated with the up-regulation of matrix metalloprotineases (MMPs). The study objective was to determine if prophylactic administration of doxycycline (an MMP inhibitor at low subantimicrobial doses) would prevent unscheduled bleeding during the initiation of a continuous OCP.
Conclusions: The coadministration of subantimicrobial-dose doxycycline during initiation of continuous OCPs results in a significant reduction in the length of time needed to achieve amenorrhea.
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Feasibility of postpartum placement of the levonorgestrel intrauterine system more than 6 h after vaginal birth
Gretchen S. Stuart, Amy G. Bryant, Erica O'Neill, Irene A. Doherty
pages 359-362
Background: The objective of this study was to determine the feasibility of postpartum levonorgestrel intrauterine system (LNG-IUS) placement on the postpartum ward.
Conclusions: Placement of LNG-IUS more than 6 h postpartum was acceptable to women in this study. The expulsion rate of 38% had statistical instability and should be interpreted with caution. However, our report may assist with individual counseling of women interested in postpartum LNG-IUS placement, or in future study designs.
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Bridge over troubled waters: considerations in transitioning emergency contraceptive users to hormonal methods
Dawn Chin-Quee, Laura Hinson, Kelly Ladin L'Engle, Barbara Janowitz
pages 363-368
Background: As emergency contraceptive pills (ECPs) become increasingly available through pharmacies, concerns about potential overuse of this product have emerged. In response, bridging women from ECPs to ongoing contraception was advanced as a solution.
Conclusion: The challenges of bridging to meet the contraceptive needs of women are discussed in light of the characteristics of emergency contraceptive users and suggest that bridging is not as straightforward as initially conceived.
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Management of the malpositioned levonorgestrel-releasing intrauterine system
Amos Ber, Daniel S. Seidman
pages 369-373
Background: The management of a malpositioned levonorgestrel (LNG)-releasing intrauterine system (IUS) can present a clinical challenge, complicated by the high cost of replacing it with a new device. We tried to challenge the guidelines and common practice that usually suggest prompt removal of any malpositioned IUS and replacement with a new one.
Conclusions: Repositioning of a malpositioned LNG-releasing IUS should be considered, as it is an easy and simple manipulation that can be done in the office with a high success rate and minimal risk of complications.
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Progestin-only contraception prevents bone loss in postpartum breastfeeding women
Maria Laura Costa, Jose Guilherme Cecatti, Fabiana G. Krupa, Patricia Moretti Rehder, Maria Helena Sousa, Lucia Costa-Paiva
pages 374-380
Background: There are an increase in bone loss during the first 6 months postpartum and a complete recovery postweaning. A few studies of steroid contraceptive use during this period provide some evidence towards protection of bone loss with progestin-only contraceptive methods.
Conclusion: Our findings suggest a preventive effect towards postpartum bone loss with progestin-only contraception in breastfeeding women.
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A successful approach to long-acting contraceptive implants in primary care
L. Anne Jeffreys, Andrew L. Clark
pages 381-383
Background: Subdermal implants of etonogestrol are an effective method of contraception but have a high discontinuation rate often due to irregular uterine bleeding. Implants are often placed in specialist environments away from the woman's usual primary health care provider in the UK.
Conclusions: Etonogestrel implants can be safely and successfully inserted in primary care by well-trained users. It is possible for well-trained users to achieve a very high device retention rate in primary care compared with published data from other practice settings.
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Tubal risk markers for failure to place transcervical sterilization coils
Ophra Leyser-Whalen, Mahta Rouhani, Mahbubur Rahman, Abbey B. Berenson
pages 384-388
Background: There is a growing body of literature on placement rates of the Essure® procedure, yet prior studies have not attempted to identify tubal-associated risk factors for placement failures. The current study examines risk markers associated with the inability to deploy the Essure® coils into the tubal lumen using the new ESS305 design.
Conclusions: We speculate that the observed association between a prior STI and an inability to place the coil was due to a past history of pelvic inflammatory disease.
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Extended regimens of the contraceptive vaginal ring versus hormonal oral contraceptives: effects on lipid metabolism
Cristina Aparecida Falbo Guazzelli, Fernando Augusto Barreiros, Ricardo Barbosa, Maria Regina Torloni, Marcia Barbieri
pages 389-393
Background: Knowledge on factors affecting acceptability of medical abortion with mifepristone followed by home administration of misoprostol is scarce. The objective of this study was therefore to assess factors affecting acceptability and experience of home use of misoprostol for medical abortion up to 63 days' gestation.
Conclusions: Home administration of misoprostol is highly acceptable. Increasing the number of complete abortions should be a focus of future research. Women should be encouraged to have a partner/friend present during home administration of misoprostol.
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Assessment of significant factors affecting acceptability of home administration of misoprostol for medical abortion
Helena Kopp Kallner, Christian Fiala, Kristina Gemzell-Danielsson
pages 394-397
Background: The study was conducted to investigate correlations between combined oral contraceptive (COC), any progestin-only contraceptive, medicated intrauterine device (MID) or systemic progestin-only (Syst-P) use and tumor marker expression in cervical intraepithelial neoplasia compared to nonusers.
Conclusions: The study showed molecular alterations, which, in general, have not been studied previously in COC users and have never been studied in progestogen-only users. These biological events might be involved in epidemiological correlations found between hormonal contraceptive use and cervical neoplasms.
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Clinical outcomes from a prospective study evaluating the role of ambulation during medical termination of pregnancy
Kamal Ojha, David J. Gillott, Patricia Wood, Elizabeth Valcarcel, Arti Matah, Vikram S. Talaulikar
pages 398-401
Background: Although induced abortion is one of the most commonly performed gynecological procedures in Great Britain and medical termination of pregnancy is being used more frequently, very little is known about the role of ambulation during the procedure. We sought to compare ambulatory and non-ambulatory groups of patients undergoing medical termination in the hospital setting and determine whether ambulation impacted clinical outcomes.
Conclusions: Ambulation during medical termination of pregnancy neither appears to influence the amount of bleeding or pain nor hasten the process of medical termination of pregnancy.
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Comparison of medical abortion follow-up with serum human chorionic gonadotropin testing and in-office assessment
Erin L. Horning, Beatrice A. Chen, Leslie A. Meyn, Mitchell D. Creinin
pages 402-407
Background: The study was conducted to compare lost to follow-up (LTFU) rates in women having a medical abortion who chose follow-up by in-office ultrasound assessment or serum beta human chorionic gonadotropin (â-hCG) testing.
Conclusions: Although LTFU rates are higher with serum â-hCG testing than in-office ultrasound follow-up in our patient population, the women who choose this method are inherently more likely not to follow-up because of other characteristics that predict a high likelihood of being LTFU. Offering serum â-hCG testing does not decrease the LTFU rate in women having a medical abortion.
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A need to expand our thinking about “repeat” abortions
Tracy A. Weitz, Katrina Kimport
pages 408-412
Background: Women who have more than one abortion are often the “targets” for social and clinical interventions geared at preventing “repeat abortions.” Such an approach ignores the unique circumstances that may surround each abortion.
Conclusions: Rather than use the term “repeat abortions,” we advocate for the use of the less loaded term “multiple abortions,” in which each abortion is understood as a unique experience.
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Women's preferences for pain control during first-trimester surgical abortion: a qualitative study
Rebecca H. Allen, Jennifer Fortin, Deborah Bartz, Alisa B. Goldberg, Melissa A. Clark
pages 413-418
Background: To explore women's preferences for pain control during first-trimester surgical abortion.
Conclusions: Most women felt that pain control decisions should be individualized.
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Development of a liquid chromatography–tandem mass spectrometry method for measuring plasma and uterine tissue levels of indomethacin in rabbits treated with indomethacin-medicated Cu-IUDs
Youping Liu, Feng Guan, Xin Wang, Xuzhe Zhang, Xin Di
pages 419-424
Background: Some side effects of copper intrauterine devices (Cu-IUDs) including increased uterine bleeding, pelvic infections and pain have been reported. The presence of indomethacin in such devices was found to be effective in relieving the symptoms. The aim of this study was to develop and validate a rapid and sensitive liquid chromatography–tandem mass spectrometric (LC-MS/MS) method for measuring plasma and uterine tissue levels of indomethacin in rabbits after insertion of indomethacin-medicated Cu-IUDs.
Conclusions: The developed method proved to be rapid and sensitive, and was successfully applied to investigate the absorption and uterine distribution of indomethacin in rabbits after insertion of indomethacin-medicated Cu-IUDs.
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Case Report

Contraceptive failure of etonogestrel implant in patients treated with antiretrovirals including efavirenz
Victoria Jennings, Irit Sinai
pages 425-427
Contraception for HIV-positive women is a complex issue. Although the use of condoms is recommended, complementary methods of contraception are often prescribed. Antiretroviral therapy can lead to drug interactions and modify the efficacy of hormonal contraception. Two unintended pregnancies suggest that etonogestrel implants should be used with caution in patients on efavirenz.
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