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Contraception Journal
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Contraception Highlights May 2013

Thinking (Re)Productively
Expert analysis on pressing issues from the Association of Reproductive Health Professionals

Who Technical And Policy Guidance Emphasizes The Health Systems' Responsibility To Provide Safe Abortion Services
Nathalie Kapp, Anna Glasier

Despite widespread availability and use of modern contraception, women around the world still experience about 85 million unintended pregnancies each year. Many of these women will seek abortion, whether under safe or unsafe conditions. The likelihood that a woman will seek an abortion for an unintended pregnancy is about the same regardless of legal restrictions. The rate of safe induced abortion has declined over recent years from 35 per 1000 women aged 15–44 in 1995 to 26 per 1000 in 2008. In contrast, the rate of unsafe abortion has remained relatively constant since 2000 at around 14 per 1000 women aged 15–44. Read more >

Editorial

Evidence-based medicine in action: the United States Selected Practice Recommendations for Contraceptive Use
Herbert B. Peterson, Willard Cates
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Commentaries

Adaptation of the World Health Organization's Selected Practice Recommendations for Contraceptive Use for the United States
Kathryn M. Curtis, Naomi K. Tepper, Denise J. Jamieson, Polly A. Marchbanks
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Evidence-based guidance on selected practice recommendations for contraceptive use: identification of research gaps
Suzanne G. Folger, Denise J. Jamieson, Emily M. Godfrey, Lauren B. Zapata,
Kathryn M. Curtis
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Review articles

When can a woman start combined hormonal contraceptives (CHCs)?: a systematic review
Dalia Brahmi, Kathryn M. Curtis
Background: Conventional methods of initiating combined hormonal contraceptives (CHCs), specifically combined oral contraceptives (COCs), the contraceptive patch and the contraceptive ring, require that women delay starting CHCs until menses begin, during which time a woman may be at risk of unintended pregnancy. The objective of this systematic review is to examine the evidence on the risk of becoming pregnant after starting the method (contraceptive effectiveness including surrogate measures such as ovarian follicular development and hormone levels), risk of already being pregnant, side effects and continuation when starting CHCs on different days of the menstrual cycle.
Conclusion: The body of evidence suggested that (a) pregnancy rates did not differ by the timing of CHC initiation; (b) the more follicular activity that occurred prior to starting COCs, the more likely ovulation was to occur; however, no ovulations were seen when COCs were started at a follicle diameter of 10 mm (mean cycle day=http://www.contraceptionjournal.org/webfiles/images/transparent.gif7.6) or when the ring was started at follicle diameter of 13 mm (median cycle day=11); (c) bleeding patterns and other side effects did not vary with the timing of CHC initiation and (d) continuation rates of CHCs were initially improved by Quick Start, but differences between groups disappeared over time.
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Pregnancies after hysteroscopic sterilization: a systematic review
Tara P. Cleary, Naomi K. Tepper, Carrie Cwiak, Maura K. Whiteman, Denise J. Jamieson, Polly A. Marchbanks, Kathryn M. Curtis
Background: Female sterilization is the second most commonly used form of contraception in the United States. Newer approaches to female sterilization, including hysteroscopic methods, have been approved for use in the United States since 2002. Little is known about the occurrence and timing of pregnancies after these procedures.
Conclusions: Fair-quality evidence suggests that among women who were followed beyond 3 months after hysteroscopic sterilization, pregnancies were rare and generally occurred among women who had no imaging follow-up or had inadequate confirmation of placement or occlusion. Few pregnancies occurred in women with documented bilateral tubal occlusion by HSG or correct placement at 3 months by ultrasound or X-ray. Only one study reported follow-up past 5 years. Further studies are needed to address the long-term effectiveness of hysteroscopic sterilization.
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Treatment of bleeding irregularities in women with copper-containing IUDs: a systematic review
Emily M. Godfrey, Suzanne G. Folger, Gary Jeng, Denise J. Jamieson, Kathryn M. Curtis
Background: Bleeding irregularities, such as intermenstrual spotting or heavy or prolonged menstrual bleeding, are common among copper-containing intrauterine device (Cu-IUD) users and are one of the leading reasons for method discontinuation. This review evaluates the evidence for effective therapeutic and preventive treatments for bleeding irregularities during Cu-IUD use.
Conclusions: Limited evidence suggests that NSAIDs may be effective treatments for bleeding irregularities associated with Cu-IUD use; antifibrinolytic agents and antidiuretics have also been studied as possible treatments in a small number of subjects, but their safety has not been well documented. NSAIDs and antifibrinolytics may also prevent bleeding irregularities among new CU-IUD users. Preventive NSAID use, however, does not impact Cu-IUD continuation.
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Treatment of unscheduled bleeding in women using extended- or continuous-use combined hormonal contraception: a systematic review
Emily M. Godfrey, Maura K. Whiteman, Kathryn M. Curtis
Background: Unscheduled uterine bleeding is common among women who choose extended or continuous combined hormonal contraception and may subsequently lead to method discontinuation. This systematic review evaluates the evidence on treatments for unscheduled bleeding for women using continuous or extended combined hormonal contraception.
Conclusion: Limited evidence suggests that introducing a short hormone-free interval when unscheduled bleeding occurs during continuous or extended hormonal contraceptive use may reduce unscheduled bleeding days; one study suggests that twice-daily oral doxycycline initiated at the time of unscheduled bleeding is an ineffective treatment. Limited data suggest that prophylactic low-dose daily oral doxycycline may induce earlier amenorrhea among new extended combined hormonal contraceptive users.
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Initiation of progestogen-only injectables on different days of the menstrual cycle and its effect on contraceptive effectiveness and compliance: a systematic review
Nathalie Kapp, Mary E. Gaffield
Background: Initiation of contraceptive progestogen-only injections conventionally require that women delay starting them until menses begin, during which time interval a woman may be at risk of unintended pregnancy. Our objective was to determine from the literature when a woman can initiate progestogen-only injectables for contraception.
Conclusion: Ovulation is rare when DMPA is provided within the first 7 days of the menstrual cycle. Use of another contraceptive as a “bridging option” until DMPA can be initiated has been unsuccessful in helping women initiate DMPA and is associated with higher rates of pregnancy.
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Prevention and management of nausea and vomiting with emergency contraception: a systematic review
Maria I. Rodriguez, Emily M. Godfrey, Meredith Warden, Kathryn M. Curtis
Background: Nausea and vomiting are side effects of emergency contraception pill (ECP) use. Different ECP regimens and the use of antinausea drugs may prevent these side effects.
Conclusion: The evidence does not support routine use of antiemetics with ECP use. Data to guide management of emesis with ECP are limited to expert opinion and package labeling.
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Advance supply of emergency contraception: a systematic review  
Maria I. Rodriguez, Kathryn M. Curtis, Mary Lyn Gaffield, Emily Jackson, Nathalie Kapp
Background: Emergency contraceptive pills (ECPs) are an underutilized means to reduce unintended pregnancy. Advance provision of ECPs may increase timely use, thereby decreasing risk of unintended pregnancy.
Conclusions: Available evidence supports the safety of advance provision of ECPs. Efficacy of advance provision compared with standard provision of ECPs in reducing unintended pregnancy rates at the population level has not been demonstrated.
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When can a woman resume or initiate contraception after taking emergency contraceptive pills? A systematic review 
Jennifer Salcedo, Maria I. Rodriguez, Kathryn M. Curtis, Nathalie Kapp
Background: Hormonal emergency contraception can postpone ovulation, making a woman vulnerable to pregnancy later in the same cycle. However, concern exists as to whether concurrently administered emergency contraception pills (ECP) and other hormonal methods of contraception may affect the effectiveness of both medications.
Conclusions: The drug manufacturer advises continuation or initiation of routine contraception as soon as possible after use of ulipristal acetate, with concomitant use of a reliable barrier method until next menses. However, a theoretical concern exists that given ulipristal acetate's function as a selective progesterone receptor modulator, coadministration of a progestin could decrease its effectiveness as an emergency contraceptive. Initiation of hormonal contraception following levonorgestrel or the Yuzpe regimen for emergency contraception carries no similar concern for decreased method effectiveness.
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How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review 
Maria W. Steenland, Maria-Isabel Rodriguez, Polly A. Marchbanks, Kathryn M. Curtis
Background: The review was conducted to examine studies that assess whether the number of pill packs dispensed, or prescribed, affects method continuation and other measures of use.
Conclusion: A small body of evidence suggests that dispensing a greater number of oral contraceptive pill packs may increase continuation of use.
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Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: a systematic review 
Maria W. Steenland, Lauren B. Zapata, Dalia Brahmi, Polly A. Marchbanks, Kathryn M. Curtis
Background: After a woman initiates certain methods of contraception [e.g., hormonal methods, intrauterine devices (IUDs)], she is generally asked to return at some interval for a follow-up visit; however, is it unclear whether follow up is needed, what an appropriate follow-up schedule is and what should be done at follow-up visits.
Conclusions: Evidence on select adverse events associated with initiation of contraceptive use is limited but does not suggest increased risk of hypertension among COC users or increased risk of PID among IUD users. DMPA users who gain >http://www.contraceptionjournal.org/webfiles/images/transparent.gif5% of baseline body weight may be at increased risk of future weight gain.
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The effect of follow-up visits or contacts after contraceptive initiation on method continuation and correct use 
Maria W. Steenland, Lauren B. Zapata, Dalia Brahmi, Polly A. Marchbanks, Kathryn M. Curtis
Background: We conducted a systematic review to assess whether follow-up visits or contacts after a woman begins using contraception improve method continuation and correct use.
Conclusions: It is difficult to determine what effect, if any, follow-up visits or contacts have on contraceptive method continuation or correct use. Few studies were identified, and those that were identified were mostly of poor quality, were not method specific and had either poor patient compliance with follow-up visits or poor phone contact completion rates.
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Blood pressure measurement prior to initiating hormonal contraception: a systematic review 
Naomi K. Tepper, Kathryn M. Curtis, Maria W. Steenland, Polly A. Marchbanks
Background: Women with hypertension who use hormonal methods of contraception may have an increased risk for cardiovascular events. This review was conducted to evaluate the evidence regarding whether blood pressure should be measured prior to initiating hormonal contraceptives.
Conclusions: Fair-quality evidence from five reports showed that women who did not have blood pressure measurement prior to COC initiation had a higher risk for AMI and ischemic stroke than women who did have blood pressure measurement. One fair-quality study showed no increased risk for hemorrhagic stroke based on whether or not blood pressure was measured. Studies that examined hormonal contraceptive methods other than COCs were not identified.
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Hemoglobin measurement prior to initiating copper intrauterine devices: a systematic review 
Naomi K. Tepper, Maria W. Steenland, Polly A. Marchbanks, Kathryn M. Curtis
Background: Women using copper intrauterine devices (IUDs) frequently experience bleeding abnormalities. This review was conducted to evaluate the evidence regarding whether hemoglobin levels should be measured prior to copper IUD insertion.
Conclusions: Limited fair-quality evidence was mixed but generally showed no clinically significant changes in hemoglobin among women with anemia who used copper IUDs for up to 12 months. Indirect evidence among healthy women using copper IUDs did not show clinically significant changes in hemoglobin levels when followed for up to 5 years of use.
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Laboratory screening prior to initiating contraception: a systematic review 
Naomi K. Tepper, Maria W. Steenland, Polly A. Marchbanks, Kathryn M. Curtis
Background: Certain contraceptive methods may increase the risk of adverse events for women with certain medical conditions, including some women with diabetes, hyperlipidemia, liver disease, cervical cancer, sexually transmitted infections (STIs) or human immunodeficiency virus (HIV). This review was conducted to evaluate the evidence regarding health outcomes among women with and without laboratory testing to identify certain medical conditions prior to initiating contraceptives.
Conclusions: While certain methods of hormonal contraception may not be safe for use by some women with diabetes, hyperlipidemia or liver disease, there is little value in screening for these conditions in asymptomatic women prior to initiation of contraceptive methods due to the low prevalence of these conditions among women of reproductive age. Although intrauterine devices (IUDs) and cervical caps should not be initiated in women with cervical cancer, the high rates of cervical screening and low incidence of cervical cancer in the United States make this scenario unlikely. Although some women at risk for, or infected with, STIs or HIV should not undergo IUD insertion, if women have been screened for STIs or HIV according to guidelines, additional screening at the time of IUD insertion is not warranted. Requiring unnecessary laboratory screening prior to initiation of contraceptive methods may impose barriers to contraceptive access, and efforts to remove such barriers are critical in reducing unintended pregnancy.
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Physical examination prior to initiating hormonal contraception: a systematic review 
Naomi K. Tepper, Kathryn M. Curtis, Maria W. Steenland, Polly A. Marchbanks Background: Provision of contraception is often linked with physical examination, including clinical breast examination (CBE) and pelvic examination. This review was conducted to evaluate the evidence regarding outcomes among women with and without physical examination prior to initiating hormonal contraceptives.
Conclusions: Although women with breast cancer should not use hormonal contraceptives, there is little utility in screening prior to initiation, due to the low incidence of breast cancer and uncertain value of CBE among women of reproductive age. Two fair quality studies demonstrated no differences between women who did or did not undergo pelvic examination prior to initiating OCs or DMPA with respect to risk factors or clinical outcomes. In addition, pelvic examination is not likely to detect any conditions for which hormonal contraceptives would be unsafe.
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Retention of intrauterine devices in women who acquire pelvic inflammatory disease: a systematic review 
Naomi K. Tepper, Maria W. Steenland, Mary E. Gaffield, Polly A. Marchbanks, Kathryn M. Curtis
Background: Women using intrauterine devices (IUDs) are not protected against acquiring pelvic inflammatory disease (PID). If a woman has an IUD in place when she is diagnosed with PID, there is a theoretical concern that presence of an IUD might impact the course of treatment. This review was conducted to evaluate the evidence regarding whether an IUD should be retained or removed if a woman develops PID.
Conclusions: Three fair-quality studies showed no difference in clinical or laboratory outcomes among women who retained IUDs when compared with women who had IUDs removed, and two of these studies showed that women who had IUDs removed had longer hospitalizations. In contrast, one fair quality study showed improved clinical signs and symptoms among women who had IUDs removed. Overall, women who retained their IUDs had similar or better outcomes than women who had their IUDs removed.
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Use of a checklist to rule out pregnancy: a systematic review
Naomi K. Tepper, Polly A. Marchbanks, Kathryn M. Curtis
Background: Safe initiation of contraceptive methods requires that pregnancy be excluded. The World Health Organization has developed a list of criteria to assess pregnancy status. This review was conducted to evaluate the evidence regarding these criteria in excluding pregnancy.
Conclusion: All four analyses demonstrated high (99–100%) negative predictive value for the pregnancy checklist.
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When can a woman have an intrauterine device inserted? A systematic review
Maura K. Whiteman, Crystal P. Tyler, Suzanne G. Folger, Mary E. Gaffield, Kathryn M. Curtis
Background: Intrauterine device (IUD) insertion during menses may be viewed as preferable by some providers, as it provides reassurance that the woman is not pregnant. However, this practice may result in unnecessary inconvenience and cost to women. The objective of this systematic review is to evaluate the evidence for the effect of inserting IUDs on different days of the menstrual cycle on contraceptive continuation, effectiveness and safety.
Conclusions: There is fair evidence (body of evidence grading: II-2, fair) indicating that timing of Cu-IUD insertion has little effect on contraceptive continuation, effectiveness or safety.
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Patient understanding of oral contraceptive pill instructions related to missed pills: a systematic review
Lauren B. Zapata, Maria W. Steenland, Dalia Brahmi, Polly A. Marchbanks, Kathryn M. Curtis
Background: Instructions on what to do after pills are missed are critical to reducing unintended pregnancies resulting from patient non-adherence to oral contraceptive (OC) regimens. Missed pill instructions have previously been criticized for being too complex, lacking a definition of what is meant by “missed pills,” and for being confusing to women who may not know the estrogen content of their formulation. To help inform the development of missed pill guidance to be included in the forthcoming US Selected Practice Recommendations, the objective of this systematic review was to evaluate the evidence on patient understanding of missed pill instructions.
Conclusions: There is wide variability in the percent of women having correct knowledge on what to do when pills are missed after exposure to written missed pills instructions, with more women knowing what to do after missing 1 pill than after missing 2 or 3 pills. Women have difficulty understanding missed pill instructions contained in patient package inserts. Providing written brochures with information on missed pill instructions in addition to contraceptive counseling may improve knowledge of how to manage missed pills. Graphic-based missed pill instructions and those containing less information may result in improved comprehension. Even with clear instructions, many women missing pills may choose not to follow the recommended actions.
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Effect of missed combined hormonal contraceptives on contraceptive effectiveness: a systematic review
Lauren B. Zapata, Maria W. Steenland, Dalia Brahmi, Polly A. Marchbanks, Kathryn M. Curtis
Background: Combined hormonal contraceptives (CHCs) are popular methods of reversible contraception in the United States, but adherence remains an issue as reflected in their lower rates of typical use effectiveness. The objective of this systematic review was to evaluate evidence on the effect of missed CHCs on pregnancy rates as well as surrogate measures of contraceptive effectiveness (e.g., ovulation, follicular development, changes in hormone levels, cervical mucus quality).
Conclusion: Most of the studies in this evidence base relied on surrogate measures of pregnancy risk and ranged in quality. For studies providing indirect evidence on the effects of missed CHCs, it is unclear how differences in surrogate measures correspond to pregnancy risk. Fewer studies examined the transdermal patch and vaginal ring than combined oral contraceptives.
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